【Abstract】 Background The hierarchical
diagnosis and treatment system has become the top priority of deepening medical
reform at present, and it is particularly important to understand its research
hotspots and evolution.ObjectiveTo systematically summarize the development
trend and evolution process of hierarchical diagnosis and treatment system in
China and grasp its knowledge base, research hotspots and development trends, in
order to provide scientific reference for subsequent research.Methods China
National Knowledge Infrastructure(CNKI) database was used as the data source
and "hierarchical diagnosis" "hierarchical treatment"
"ladder network of medical prevention" "hierarchical medical
system and division of labor in blocks" "hierarchical medical and
service system and division of labor in blocks" "hierarchical medical
system and division of labor" "initial diagnosis in community"
"initial diagnosis at grassroots level" "treating acute and
chronic diseases separately" "two-way referral"
"cooperation between superior and subordinate medical institutions"
"different division of labor in diagnosis" "different division
of labor in treatment" "orderly medical diagnosis" "orderly
medical treatment" "health service system+integration"
"health service system+hierarchical" and "health service
system+collaboration and division of labor" were used as key words to
retrieve the documents related to the hierarchical diagnosis and treatment
system in China from January to July in 2019.The retrieval time was from
January 1, 1949 to July 31, 2019.Excel was used to retain and analyze the data,
and descriptive statistical analysis was made on the authors, titles, document
sources, publishing institutions, and volume of publications of the included
documents.CiteSpace was used to obtain published journals, institutional
cooperation and author distribution of the research results of China's
hierarchical medical system.Through the analysis of high-frequency keywords, research
hotspots were identified.Through time zone maps, clustering words and emergent
words, the frontiers and development trends of the research were determined.Results In the end, 1233 articles were included, and the journal with the largest
number of publications were Chinese General Practice〔287(23.28%)〕.The top five journals
with the most published articles were all from the core database of Peking
University Library(a total of 729 articles) with more than half of the total
published articles.The institutions with high yield of research results were
mainly centered around Huazhong University of Science and Technology, Capital
Medical University, National Health Commission, Fudan University and Peking
University.There were 68 core authors with a total of 457 articles, accounting
for 37.28% of the total literature."Community health service"
"medical alliance" "influencing factor" and "general
practitioner" had always been hot topics in the research field of
hierarchical diagnosis and treatment.The clustering labels of "patriotic
health movement" "hospital bed" and "outpatient", and
key words of "effect evaluation" "influencing factors" and
"medical treatment" appeared from 1949 to 1978.The clustering labels
of "medical treatment" and "medical insurance system", and
key words of "community health service" "two-way referral"
and "community health service institution" appeared from 1979 to 2008.The
clustering labels of "grassroots medical and health institution"
"combination of medical and nursing care" "medical service
system" and "medical insurance", and key words of "medical
service system" and "hierarchical diagnosis and treatment"
appeared from 2009 to 2018.Conclusion The increase rate of literature of
China's hierarchical diagnosis and treatment system is accelerated, but the
quality of research results need to be further improved.There are a lot of
cooperation among institutions, but the cooperation and communication among
authors are limited, and no stable core author group has been formed.The
research hotspots are gradually diversified and the research directions are
continuously refined. How to find a new way of innovation from the
institutional level through closer communication and collaboration is worthy of
further study.
【Key words】Hierarchical diagnosis
and treatment;Research hotspots;Research evolution;Bibliometrics
The hierarchical
diagnosis and treatment system refers to the hierarchical of diseases according
to the severity of diseases and the difficulty of treatment. Medical
institutions of different levels undertake the treatment of different diseases,
forming a diagnosis and treatment order of "primary treatment at the
grassroots level, two-way referral, separation of urgent treatment and slow
treatment, and linkage of upper and lower levels". Under the hierarchical
diagnosis and treatment system, the general outpatient services, rehabilitation
and nursing services undertaken by large and medium-sized hospitals are
transferred to primary medical and health institutions, resulting in the
decline of medical resources[1]. The hierarchical diagnosis and
treatment system is an important issue in deepening the medical reform in China.
The implementation of this system is conducive to the maximum efficiency of the
use of health resources, the refinement of patient services and the guarantee
of everyone's access to basic medical services.
The system of hierarchical
diagnosis and treatment has long been formed in foreign countries. The United
Kingdom is one of the early representatives who strictly practiced the system
of hierarchical diagnosis and treatment. The National Health Service Act was
enacted in 1948 and the National Health Service (NHS) was established[2].
The United States is the world's typical representative of medical
marketization, effectively forming a hierarchical medical treatment model
through the medical insurance system[3]. Canada implements strict
hierarchical diagnosis and treatment, and patients cannot go to secondary
medical service institutions without the recommendation of family doctors[4].
Chinese scholar Yang et al.[5-6] published a series of literature on
China's medical reform in the Lancet, pointing out that the disease spectrum in
China has changed significantly in the past 30 years, from the former
infectious diseases and perinatal diseases to chronic non-infectious diseases.
The effective strategy to deal with the current situation is to establish a
good hierarchical diagnosis and treatment system. Combined with the research
results of many scholars, the General Office of the State Council issued the
Guiding Opinions on Promoting the Construction of the Hierarchical Diagnosis
and Treatment System in 2015 (Guo Ban Fa [2015] No. 70), which marked that the
hierarchical diagnosis and treatment system officially became the most
important starting point for deepening the medical reform and became the key to
the success or failure of the new medical reform. Therefore, it is necessary to
comprehensively grasp the past, present and future of the research on
hierarchical medical system. Based on this, this paper, from the perspective of
bibliometrics knowledge map, sorted out the journals and literatures in the
research field of hierarchical diagnosis and treatment system, clarified the
development trend and evolution process of the research, analyzed the research
hot spots and cutting-edge research results in this field, and provided
scientific reference for future research.
1 Materials and methods
1.1 Literature search
From January to July 2019,
CNKI database will be used as the data source. The concept of the hierarchical
system in the early call "ladder network of medical treatment, prevention
and health care", 1954 years later changed to "blocks hierarchical
division of medical service system", the eighteenth big used to call it
the "community first option" first option "base layer"
"two-way referral" “hierarchical health", after the new reform
according to connotation points level diagnosis system is called" the
first option at the grass-roots level, two-way referral, acute slow partition, the
upper and lower linkage ", through literature reading, found
"division of diagnosis and treatment" "division of medical"
orderly "medical" orderly "diagnosis" "integration of
medical service system" "medical treatment organization
collaboration" similar to "hierarchical diagnosis and treatment".
To sum up, in order to ensure the accuracy and comprehensiveness of literature
retrieval, with "hierarchical diagnosis" "points level
medical" "ladder medical prevention network" "blocks
hierarchical division of medical system" "row area hierarchical
division of medical service system" "hierarchical division of medical
system" first option "community" "first option at the
grass-roots level", "urgent slow divide and conquer" the
"two-way referral" "the upper and lower linkage"
"division of diagnosis and treatment" "division of medical"
orderly "medical" "orderly clinical therapy" "health
service + integrated" "+ hierarchical of health service system"
"the medical treatment organization + collaboration" as the keyword
search, retrieve the entry for "main topic", The retrieval time is
set to 1949-01-01 to 2019-07-31.
1.2 Inclusion and exclusion
criteria
Inclusion criteria :(1)
literature related to hierarchical treatment system; (2) Literature is in
Chinese; (3) Literature types are journal papers. In order to ensure the
quality of research, journal sources are Science Citation Index (SCI), Engineering
Index (EI), Chinese Core Keys General of Peking University, and Chinese Social
Sciences Citation Index. CSSCI) and Chinese Science Citation Database (CSCD).
Exclusion criteria: excluded newspapers, conference abstract literature, newspaper
and periodical report literature, diagnosis and treatment guidelines, thematic
discussion, exclusive interviews and abstract irregularities, invalid
institutions, lack of authors, and literature unrelated to the research topic.
1.3
Literature screening, data extraction and quality assessment
Data were stored in
RefWorks and Excel format, and literature was manually sorted and screened.
During literature screening, the papers with the same name, author, journal and
publication time were defined as repeated papers, which were combined into one
included study. Replicative screening was performed by the investigator and
checked two weeks later. After the articles are checked, literature screening
is strictly carried out according to the inclusion criteria and exclusion
criteria.For the controversial literatures, whether to be included or not is
determined after discussion with relevant personnel.For the literature included
in the study, the researchers extracted the article information and made
further econometric analysis.
1.4Statistical
Methods
Excel was used to retain
and analyze the data, and descriptive statistical analysis was conducted on the
information of the included literature, such as author, title, literature
source, publication organization, publication volume, etc. Scientific knowledge
map in literature metrology, information metrology and metrology is widely used
in fields such as, not only can through the visual way to show a certain source
of scientific knowledge in the field of research, development, knowledge
architecture and research frontier of literature can be effectively mining
hidden characteristics, patterns and trends, as the research in the field of a
scientific knowledge to provide a unique perspective[7].CiteSpace
was prepared for America's Drexel University computing machines and information
science beauty professor Chen information of visual software developed by using
Java language, as the world's emerging scientific knowledge map drawing tools, in
acquiring knowledge in the field of research foundation, research frontier and
hot spots, analysis and research fields of scientific knowledge structure, insight
into the evolution process, etc., have the computing power and force[8].
Therefore, in this paper, RefWorks format data were imported into
CiteSpace(version :5.3.R4.8.31.2018) for analysis to obtain the journals, institutional
collaborations and author distribution of the research results of China's
hierarchical medical system. Through the analysis of high-frequency keywords, the
hot research areas are determined. Through time zone diagram, cluster words and
emergent words, the research frontiers and development trends were determined.
2 Results
2.1
Literature retrieval results
At first, 1685 records
were retrieved from the database, and 452 literatures were removed by the
literature de-merging and inclusion and exclusion criteria, finally 1233 valid
literatures were obtained.
2.2
Publication time and quantity distribution of included literatures
After sorting out 1233
literatures, the detailed number and growth trend of literatures on the
research of China's hierarchical medical system from 1949 to 2019 were obtained,
and the cumulative number of literatures increased in the form of approximate
exponents over time. Among them, the number of published articles from 1949 to
1978 was less, with a total of 19. From 1979 to 2008, the number of papers published
showed an increasing trend (from 1 to 30), and 142 papers were published in
total. From 2009 to 2018, the number of papers published increased rapidly
(from 48 to 233), with a total of 992 papers published (Figure 1).
2.3
Distribution of published journals, cooperative institutions and authors on the
research of China's hierarchical medical system
2.3.1
Distribution of published journals on the research of China's hierarchical
medical system
The top 5 journals in the
list of published articles were: Chinese General Practice (287 articles, 23.28%),
Chinese Hospital Management (137 articles, 11.11%), Chinese Health Economy (126
articles, 10.22%), Chinese Health Service Management (98 articles, 7.95%), and
Health Economy Research (81 articles, 6.57%). Among the top 15 published
journals, 9 journals belong to the source journals of Peking University's
Chinese Core Periodical Contents, 4 journals are from CSCD, 2 journals are from
the database of Japan Agency for the Promotion of Science and Technology (JST),
and no CSSCI. The top 5 journals were all from the General Catalogue of Chinese
Core Journals of Peking University, with a total of 729 articles published, more
than half of the total (Table 1).
Table 1 Distribution of source journals on hierarchical
diagnosis and treatment system in China from 1949 to 2019(top 15)
|
Ranking
|
Journals
|
Number
|
Percentage
|
Source
|
|
1
|
Chinese General
Practice
|
287
|
23.28
|
Core of Peking University
|
|
2
|
Chinese Hospital
Management
|
137
|
11.11
|
Core of Peking University
|
|
3
|
Chinese Health
Economics
|
126
|
10.22
|
Core of Peking University
|
|
4
|
Chinese Health
Service Management
|
98
|
7.95
|
Core of Peking University
|
|
5
|
Health Economics
Research
|
81
|
6.57
|
Core of Peking University
|
|
6
|
Chinese Journal of
Health Policy
|
60
|
4.87
|
CSCD
|
|
7
|
Medicineand Philosophy
|
37
|
3.00
|
JST
|
|
8
|
Modern Preventive
Medicine
|
27
|
2.19
|
Core of Peking University
|
|
9
|
Medicine and
Society
|
24
|
1.95
|
Core of Peking University
|
|
10
|
Chongqing Medicine
|
24
|
1.95
|
JST
|
|
11
|
Chinese Health
Resources
|
24
|
1.95
|
Core of Peking University
|
|
12
|
Chinese Journal of
Public Health
|
15
|
1.22
|
CSCD
|
|
13
|
Chinese Nursing
Management
|
13
|
1.05
|
CSCD
|
|
14
|
Chinese Journal of
Health Statistics
|
9
|
0.73
|
CSCD
|
|
15
|
Population and
Family Planning
|
8
|
0.65
|
Core of Peking University
|
Note: Core of Peking University=General Overview of Chinese
Core Keys of Peking University, CSCD=Chinese Science Citation Database, JST=Japan
Science Technology Corportion
2.3.2
Distribution of cooperation institutions in China's hierarchical medical system
research
The refining statistics
of 1233 literatures were carried out according to the sources of research
institutions, and the data was imported into CiteSpace software. Institutions
in Node Types were selected, Pathfinder algorithm was selected, and other
options were set as the default. In the output results, the circular coverage
area (represented by the font size of the research institution) represents the
occurrence frequency of the author's signature institution. The larger the area,
the higher the occurrence frequency. The lines between the circles represent
the cooperation between institutions. The lines are directly proportional to
the frequency of cooperation, and the line nodes are the cooperation centers.
The hierarchical system
in the country study the distribution of productive organizations, mainly
including Agencies group 1: Huazhong university of science and technology, Tongji
medical college medical institute of medicine health management as the core, and
has cooperation withthe humanities and social science in Hubei province key
research base of rural health services research center, Nanjing institute of
major medical study medicine administration, according to the righteous medical
school, school of management, Hubei university of political science and law and
public management institute, China university of science and technology in
school of economics, Huazhong university of science and health policy and
management research institute (think-tank), Shenzhen Guangming New District
Gongming Hospital, School of International Medicine, China Pharmaceutical
University, etc..Agencies group 2:School of Health Management and Education, Capital
Medical University and Health Development Research Center of the former
National Health and Family Planning Commission as the core, and has cooperation
withthe National health committee, the original Beijing Municipal Commission of
Health and Family Planning, the original Health and Family Planning Commission
of Heilongjiang Province, the original Health and Family Planning Commission of
Heilongjiang Province, School of Public Administration, RenMinUniversity of
China, Beijing DitanHospital, Beijing Children's Hospital, Capital Medical Universit,
Beijing Xicheng District Community Health Service Management Center, Weifang Medical
UniversitySchoolOf Public Health, YouJiangMedical UniversityforNationalities, Chinese
Academy of Medical Sciences Institute of Medical Information, andsoon.
Institutional Cooperation Group 3: With School of Social Development and Public
Policy of Fudan University as the core, cooperated with School of Public Health
of Fudan University and former Health and Family Planning Commission of
Changning District, Shanghai, etc. Institutional Cooperation Group 4: China
Health Development Research Center of Peking University asthe core, and has
cooperated with School of Public Health of Peking University, etc. (Figure 2).
2.3.3 Distribution of
authors in the study of China's hierarchical medical system
The refining statistics
of 1233 literatures were conducted according to the core authors and the
cooperation between authors. Data was imported into CiteSpace software, Author
in Node Types was selected, Pathfinder was selected by the algorithm, and other
options were set as the default. The results of the core authors (the first 22)
are shown in Table 2, and the cooperation among authors is shown in Figure 3.
Due to the limitation of
software function, the published statistics of authors cannot be identified as
the corresponding author or the first author for the time being. Therefore, there
may be cumulative studies in the research field of the hierarchical diagnosis
and treatment system in which the author has published articles other than the
corresponding author or the first author. Statistical analysis showed that the
cumulative number of papers published by the most scholars was 26. According to
the "square root law" proposed by Price, the number of core authors
in a research field can be determined. The formula is:N=0.749×nmax
Table 2 Distribution of core authors of the study on
hierarchical diagnosis and treatment system in China from 1949 to 2019(top 22)
|
Ranking
|
Author
|
Frequency
|
Organization
|
Ranking
|
Author
|
Frequency
|
Organization
|
|
1
|
Zhang L
|
26
|
Huazhong University of Science and Technology
|
12
|
Miao C X
|
9
|
Xuzhou Medical University
|
|
2
|
Fang P Q
|
19
|
Huazhong University of Science and Technology
|
13
|
Wang C X
|
9
|
Tongji University
|
|
3
|
Zhang Y
|
18
|
Huazhong University of Science and Technology
|
14
|
Zhen J
|
8
|
Xuzhou Medical University
|
|
4
|
Feng Z Y
|
13
|
Chongqing Medical University
|
15
|
Liang H
|
8
|
Fudan University
|
|
5
|
Qian D F
|
11
|
Nanjing Medical University
|
16
|
Li H H
|
8
|
Xuzhou Medical University
|
|
6
|
Gan X Q
|
11
|
Jiujiang University
|
17
|
Lei G H
|
7
|
Guangdong Medical University
|
|
7
|
Kuang L
|
10
|
Sun YAT-SEN University
|
18
|
Tao H B
|
7
|
Huazhong University of Science and Technology
|
|
8
|
Zhuo L
|
9
|
Xuzhou Medical University
|
19
|
Du X P
|
7
|
Fuxing Hospital
|
|
9
|
Zhao S H
|
9
|
Xuzhou Medical University
|
20
|
Luo L
|
7
|
Fudan University
|
|
10
|
Jiang J X
|
9
|
Xuzhou Medical University
|
21
|
Zhang T T
|
7
|
Fudan University
|
|
11
|
Lu Z X
|
9
|
Huazhong University of Science and Technology
|
22
|
Dai R M
|
7
|
Fudan University
|
2.4 Research hotspots of
China's hierarchical medical system
The research hotspot is
usually the common concern of the closely related and numerous literatures in a
certain period of time. Key words are the author's highly condensed research
content, which can well reflect the core content of the article. Therefore, through
the statistical analysis of the frequency of the occurrence of key words, we
can well grasp the research hot spots in this field.[10]Review found
that couplet of "medical" and "medical association", "impact
factor" and "factor analysis" as a concept, the number of high
frequency can be stacked, so, after finishing the data import CiteSpace
software, select the Node type (Node Types) of keyword (Key word), algorithm
selection Pathfinder and Pruning sliced networks, and other options in
accordance with the default Settings. The hot point knowledge map of China's
hierarchical diagnosis and treatment system was obtained. The larger the font
in the map, the higher the frequency of the keyword.The results showed that the
top five keywords were community health service (364 times), influencing
factors (337 times), medical confederation (243 times), general practitioner
(185 times), and effect evaluation (152 times).In terms of centrality value, the
top five centrality were "community health services" (0.24), "medical
confederacy" (0.22), "influencing factors" (0.19), "medical
insurance" (0.13) and "general practitioner" (0.12), besides
"hierarchical diagnosis and treatment" and "two-way
referral", which were the strongest research topics.In terms of outbreak
points, the top five hot spots were "influencing factors" (69.59), "community
health services" (42.28), "effect evaluation" (37.29), "general
practitioners"(28.58), and"medical association" (10.15).Thus, "community
health services", "medical confederacy", "influencing
factors" and "general practitioners" have always been hot terms
in the research field of hierarchical diagnosis and treatment (Figure 4).
It is important to note that
the sequence and the sequence of the centricity can be found by comparing the
keywords, the sequence of the part of the word frequency is not high but the
sequence of the centricity is higher, mainly for: "medical service
system", "diabetes" "medical resources" "primary health
care, " "family doctor service contract", "healthy
China" shows that a lot of research around the health under the background
of China, the family doctor to sign, chronic diseases, between the hospital and
community medical institution reform research.
2.5 Evolution of China's
hierarchical medical system
To overall analysis our
country the hierarchical system research in the field of knowledge base
structure and the evolution process, in this paper, the Time in a 1233
documentary by CiteSpace software - zone view, select 10 years as a Time
section display keywords network node the structural relationships change over
Time, and according to the automatic clustering graph clustering algorithm, using
the logarithmic likelihood ratio algorithm to extract clustering tags, and the
top 10 emergence nouns.
The results show that
"patriotic health movement", "bed" and
"outpatient" cluster labels appeared from 1949 to 1978. From 1979 to
2008, "medical treatment" and "medical insurance system"
cluster labels appeared. From 2009 to 2018, "primary medical and health
institutions", "combination of medical and nursing care", "medical
service system" and "medical insurance" cluster labels appeared
(Figure 5). From 1949 to 1978, the key words "effect evaluation", "influencing
factors" and "medical treatment" appeared. From 1979 to 2008, "patient",
"community health service", "two-way referral" and
"community health service institution" appeared. From 2009 to 2018, "hierarchical
medical care", "medical service system" and "hierarchical
diagnosis and treatment" appeared (Figure 6).
3 Discuss
3.1 Research literature
characteristics analysis of China's hierarchical medical system
Combined with the changes of
China's social and economic system, medical service system and the implementation
of relevant policies, it can be divided into three stages. (1) Initial
exploration stage (1949-1978): This stage was the planned economy period at the
beginning of the founding of the People's Republic of China. The country
implemented the "medical service system based on regional division of
labor" and initially formed the hierarchical diagnosis and treatment
pattern. However, there were few relevant literatures, with an average of no
more than one paper per year. (2) Stable rise stage (1979-2008): This stage was
from the early stage of China's reform and opening up to the early stage of the
new medical reform. China's hierarchical diagnosis and treatment experienced a
process from becoming loose to re-exploring and returning. Therefore, the number
of relevant research literatures increased year by year and showed a steady
rise trend, reaching a peak of 30 in 2008. (3)Rapid development stage
(2009-present): After the new medical reform in 2009, the government put
forward the importance of hierarchical diagnosis and treatment again, and took
it as an important push to deepen medical reform in 2015. Therefore, the number
of literatures at this stage showed a rapid rise. Especially after 2015, the
number of articles published each year was basically maintained at more than
100, and the annual average number of articles was 185.
3.2 Analysis of high-yield
journals, institutional cooperation and author distribution in China's
hierarchical medical system
In terms of the distribution
of high-yield journals, although the journals in their research fields have
disadvantages in academic circles, it also reflects to some extent that the
research results of hierarchical diagnosis and treatment in China need to be
further strengthened and improved.
Look from distribution
agencies, the health administrative organization (government actors) and
government research institutions, medical institutions, schoolsresearch
institution, interest groups (health services organizations, such as hospitals,
community health service centers) actively involved in the hierarchical system
research, and constitute the main body of research in colleges and universities,
academic cooperation broke the traditional disciplinary boundaries, to promote
the progress and development of the hierarchical system research.
Core author refers to a
scholar who has great influence and plays an important role in a certain
research field. Scientific research is often a team activity, and most articles
are completed through collaboration among authors. Authors learn from each
other's strengths to improve the depth and breadth of research.[11] Therefore, it is very important to analyze the distribution of cooperation
between the core authors of the literature.According to the statistical results,
the total number of core authors is less than half of the total number of
papers, it can be concluded that China has not formed a stable core group of
authors in the research field of the hierarchical diagnosis and treatment
system.
From the perspective of the
distribution of cooperation among authors, the cooperation and communication
among the authors of the research on the system of hierarchical diagnosis and
treatment is relatively limited, and the cooperative groups formed are more
frequent within the group and less among the groups, which is not conducive to
the improvement of the research level of hierarchical diagnosis and treatment, which
may be related to the different research points of different authors. At
present, a group of authors with Zhang Liang, Fang Pengqian, Lu Zuxun, Wang
Chaoxin, Zhuo Lang and Liang Hong as the core has been formed in domestic
research. Zhang Liang's team from the School of Health Management, Tongji
Medical College of Huazhong University of Science and Technology mostly studies
the hierarchical diagnosis and treatment system from the perspective of
township and county medical institutions. Fang Pengqian's team from the
Institute of Health Policy and Management of Huazhong University of Science and
Technology mainly studied the hierarchical diagnosis and treatment system from
the perspective of medical association, "three-medical linkage" and
public hospitals. Lu Zu Xun's team from the School of Public Health, Tongji
Medical College, Huazhong University of Science and Technology (HUST) mainly
discusses from the perspective of "community first diagnosis".
Wang ChaoxinfromTongji
university school of medicinehas cooperation with both research network, one is
with Luoli, Baige and Zhang tian-tian from Fudan university school of public
health, focused on clinics, rehabilitation and long-term care shunt hierarchical
diagnosis and related studies.
The other is the cooperation
with the affiliated hospital of Tongji University, mainly studying the status
quo of bidirectional referral criteria for hypertension, the systematic
evaluation of the status quo ofhierarchicaldiagnosis and treatment in Shanghai
and explore the three-dimensional collaborative mode of regional health based
on hierarchical diagnosis and treatment.Zhuo Lang from Xuzhou Medical
University and other researchers mainly studied hierarchical diagnosis and
treatment from the awareness rate and willingness of residents (demanders) in
Xuzhou. Liang Hong's team from the School of Social Development and Public
Policy of Fudan University conducted research from the perspectives of
"medical association" and "contract system of family
doctors".
3.3 Evolution analysis of
China's hierarchical medical system
According to the above three
development stages (initial exploration stage, steady rise stage, and rapid
development stage), and the analysis of the key node literature, influential
literature, published authors and other information in each stage, the research
evolution and development trend of this research field in the past 70 years can
be revealed.
3.3.1 Initial Exploration
Stage (1949-1978)
In the early days after the
founding of the People's Republic of China, the state put forward the
"ladder medical prevention network", which was later the
"medical service system based on district division and division of
labor", which was adopted at the National Health Conference in 1956 after
being tested in some provinces and cities.This system is mainly for the
convenience of the masses to go to a doctor nearby, to overcome the crowded and
busy phenomenon of large hospitals and improve the quality of medical treatment,
through the unified layout planning, the province, city, county (district)
three level hospitals and grass-roots medical and health institutions organically
constitute the medical and health network, according to the regional hierarchical
division of labor and business guidance contact. Countries in this time period
also released the measures for the implementation of the national worker
medical treatment to prevent (1952), the Ministry of Finance, the ministry of
health on consolidation and strengthening medical treatment management work
notice (1978), the articles of association of rural cooperative medical care
system (1979), such as file requirements shall, first of all, in the patients
with medical institutions, adhere to strict referral program, without approval
and referral referrals, unable to get the reimbursement. The government has set
up a three-tier medical system in urban and rural areas. The health care system
is centered on "primary health care". The health care system is fully
funded by the government, and the government implements the public health care
system for government organs and public institutions, the enterprise labor
insurance medical system, and the rural cooperative medical system. [12] During this period, "blocks hierarchical division of medical service
system" and the planned economy system, under the condition of the weak
economy, through three more strict control of medical treatment insurance, under
the condition of ensure the basic medical services a "specified type to
see a doctor", promote the vaccine to eliminate pests, in order to control
the disease such as smallpox, malaria, schistosomiasis, quickly improve the
health level of the masses, form a pattern of essentially the hierarchical of
diagnosis and treatment, known by the world health organization (who) as the
model of medical and health system.[13]
Stage of the academics around
the effect of "blocks hierarchical division of medical service
system", solve the problem of outpatient crowded, how to do a good job of
prevention and management under the system of "socialized medicine"
to save medical resources, avoid the waste of medical insurance funds aspects
are studied, thus the dash forward show the noun "influencing
factors", "performance evaluation" clustering words
"patriotic health campaign" "bed" "outpatients.The Cai
Hengfang[14] is introduced using scribing point of Beijing, reorganization
of medical institutions, to set up similar couplet of the medical model of
medical institutions between the superior and the subordinate business
leadership, we must adjust the relationship between health and propaganda
education way to carry out the hierarchical division of medical treatment, can
solve the problem of uneven hospital busy idle, to facilitate the masses to go
to a doctor, improving medical technology level, promote the purpose of
prevention work.LiuShao-zhu[15]put forward "three long and one
short" problem should be deal with hospital executive blocks hierarchical
division of the medical system to improve the medical order, and to all levels
of different kinds of tasks should be different and collaboration with each
other, form an organic whole, help grassroots health institutions will assume
the task of common frequently-occurring disease, convenient to the masses, to
the nearest according to undergo, alleviate the problem of large hospital
outpatient medical consultations.Sun Jiaxian[16]consider that in Heilongjiang
province after the implementation of "blocks hierarchical division of
medical service system", is beneficial to improve the level of hospital
management and medical quality, to give full play to the potential factory
enterprise systems such as hospital, to establish policy of medical order and
step by step business technical guidance, to mobilize the enthusiasm of the
grassroots health institutions, put forward the system can be implemented in
the country and shall establish the national medical college center, establish
the national urban and rural medical and health web.In order to solve the
problem of overspending on public health care, Huang Yun[17] believed
that the main reason is that there are deficiencies in management, such as lax
control of treatment, referral and reimbursement procedures, and that medical
institutions do not grasp the principles of treatment, leading to the
occurrence of more prescriptions and more inspections.Liu Ruiqing[18] believes that the "partition package, classification of
responsibility", which not only ensures the treatment and can overcome the
problem of medical institutions just treatment regardless of saving, strict
implementation of hospitalization, hospital transfer, hospitalization system to
reduce unnecessary medical costs, strict investigation of the side and
financial accounts, etc.Hua Ying[19] pointed out that preventive
health care is the most effective way to save medical costs, and management, treatment
and health care should be combined. Patients who need to be referred should go
to a designated hospital for treatment, and patients who need to be referred
should have a letter of referral before reimbursing medical expenses.From 1949
to 1978, the practice of medical confederacy had been established, and some
scholars proposed to establish several specialized medical centers throughout
the country. However, in general, there were not many research achievements in
this field during this period, and it has not been widely concerned by
researchers.
3.3.2 Stable rising stage
(1979-2008)
During this period, from
China's reform and opening up to the early stage of the implementation of the
new medical reform, the hierarchical diagnosis and treatment system experienced
a process from loosening to being reexplored. The market-oriented
transformation of China's social and economic system has promoted the
market-oriented transformation of the medical and health system, and the
hierarchical diagnosis and treatment model has been impacted. Under the
competition mode, hospitals are getting stronger and stronger due to the more
resources they occupy, the function orientation is gradually blurred, and the
service ability of primary medical and health institutions is gradually reduced.
The economic recovery has released people's demand for medical services, and
the reconstruction of the three major medical insurance systems has increased
patients' choice of medical treatment, prompting patients to flock to large
hospitals, forming a "free choice" medical treatment mode. The
hierarchical diagnosis and treatment pattern has been completely broken, and
the flow of medical treatment presents an "inverted pyramid" pattern.
With the increasingly prominent problems of difficult and expensive access to
medical services, the poor performance of the market-oriented reform of the
medical system and the serious problems of disordered medical treatment, the
state began to pay attention to the construction of primary medical care. In
1999, the former Ministry of Health issued Several Opinions on the Development
of Urban Community Health Services (Weiji Women [1999] No. 326), which put
forward the guideline of strengthening the capacity building of primary medical
services. In 2006, the State Council promulgated the Guiding Opinions of the
State Council on the Development of Urban Community Health Services (Guo Fa
[2006] No. 10), which proposed for the first time in the state document to
"establish a system of hierarchical medical treatment and two-way referral,
and explore the pilot of community first-visit system". In 2007, as the
former Ministry of Health launched the two-way referral hierarchical diagnosis
and treatment system to alleviate the problem of difficult and expensive
medical treatment, the idea of hierarchical diagnosis and treatment became
clear [12-13].
At this stage, the number of
research results began to increase gradually, reaching 30 by 2008, and the
research in this field began to become active. At this stage, scholars mainly
focus on the research on whether the "medical service system of zoning and
grading division of labor" is in line with the current stage of
development, the hierarchical management and evaluation of hospitals, the
construction of medical confederacy, the new three major medical insurance, and
the research on community medical institutions and two-way referral after
re-exploration. Because of this, the key node of "two-way referral"
and the cluster words of "community health service" and "medical
insurance system" appear. In terms of research methods, they mainly focus
on theoretical discussion, questionnaire survey, interview, empirical analysis
and descriptive statistics.
With the convening of the
Third Plenary Session of the Eleventh Central Committee in December 1978, China
established the development direction of economic construction as the center, and
the medical and health field also moved toward marketization, and the
"medical service system of zoning and grading division of labor" had
some contradictions with the current development. In 1984, Zhou Shouqi[20] published the article "Question on Medical Service in Zoned Areas", which
affirmed the positive role of the zoned medical service system with
hierarchical division of labor, but also pointed out its existing contradictions:
with the improvement of people's living standards, the demand for preferential
medical treatment increases; Competitive pressure is beneficial to the
improvement of medical level of medical institutions, so the autonomy of
medical treatment units should be opened up. Nearby medical treatment rather
than zoned medical treatment can be more convenient for people to see a doctor;
With the increase of specialized demand, many patients cannot be covered
"systematically and comprehensively" by zoned hospitals. The basic
reason is that the "medical service system based on division of labor by
district and level" does not adapt to the development of social demand at
the present stage, so necessary adjustment and reform should be carried out.
The author believes that a more flexible hierarchical form of "selective
medical treatment" can be realized from the aspects of public opinion
survey, developing its own technical characteristics, and carrying out two-way
referral. During this period, all kinds of medical couplet body construction
began to flourish, LiuTie-jun[21]use"xiao cui find
diagnosis" as a guide, put forward implementation steps, the medical care
system is the necessity of couplet of "medical" construction, through
the large hospital and small and medium-sized hospital established cooperation
relations, not only will bypass patients, alleviate the pressure of the large
hospital beds tight, also make the small and medium-sized hospital doctors
medical technology level, incalculable to the promotion of social benefit.HuaZu-xing[22] pointed out such as Shenyang in 1984 created the first "consortium", becausethe
medical association has the advantages of voluntary combination, flexible
cooperation mode and so on, by the year
1988 has developed 238 (including 35 and other provinces and cities). While
" medical treatment alliance " has brought benefits in various
aspects, some problems such as blind association, simple pursuit of economic
benefits and disguised charge for improper examination have also appeared.At
the same time, he believed that the existing loose type of medical
confederations with technical cooperation as the main body will transition and
develop into intensive medical groups, from technical cooperation to entity
joint management.In June 1989, Zhou Qi[23] published "On the
Implementation of Hospital Evaluation and Hierarchical Management System"
in Management World. He proposed that, based on the experience of
foreign advanced developed countries and China's national conditions, hospitals
should implement a hierarchical management system, which could be divided into
three levels corresponding to the corresponding institutions, functions and
tasks.In November the same year the ministry of health issued "hospital
classification management method (trial draft), the hospital according to the
function, task, facilities, technology and medical quality integrated level is
divided into three ten hierarchical management etc., the ministry of health
issued"planning and guiding principles of the establishment of medical
institutions"in 1994, put forward to set up the levels clear, structure is
reasonable, function in three level hospitals, set up suitable for the
situation of medical and two-way referral framework.During this period, a large
number of articles on hospital hierarchical management and evaluation have also
emerged. Since 1998, China's medical security system has undergone great reform.
The basic medical insurance system for urban employees (1998), the new rural
cooperative medical system (2003) and the basic medical insurance system for
urban residents (2007) have been established successively.Tan Shen-sheng[24] believes that with the deepening of the reform of the urban medical insurance
system, the autonomy of the masses in medical treatment is released, which
leads to the flow of patients to large hospitals, leading to overcrowding in
large hospitals while small hospitals are deserted. Community health services
should be vigorously developed to provide convenient, continuous, comprehensive,
coordinated and cheap health services.Analysis from the perspective of
literature cited frequency, the highest amount of the citedwas Li Xiaoxiao[25] from Renaissance hospital affiliated to the capital university of medical
sciences, published in the Chinese General Practiceof "The problems
and countermeasures of dual referral system in China", in contrast to
foreign two-way referral implementation present situation, proposed our country
two-way referral is the easy to the difficult, lack of referral standards, incentive
and constraint mechanism, market economic system under the conflict of economic
interests, community hospital service ability is weak, the information sharing
between the difficult problems, such as medical institutions.Followed by Qi Xiaolin[26]from
health management and policy research center of Shandong university published
"On obstacle and countermeasure of community health services in
China". She believed that China's community health services were still in
the primary stage, and there were still some problems, such as the
uncoordinated technical level of general practitioners, the incomplete
"six-in-one" function, and the imperfect two-way referral system, compensation
mechanism and medical insurance system.
3.3.3 Rapid development stage
(2009 to present)
In April 2009, the CPC
Central Committee and the State Council issued the Opinions on Deepening the
Reform of the Medical and Health System (Zhongfa [2009] No. 6) to start a new
round of medical reform, which defined the policy framework of hierarchical
diagnosis and treatment. In 2014, Premier Li Keqiang proposed to improve the
hierarchical diagnosis and treatment system, strengthen the training of general
practitioners, promote the practice of doctors in multiple locations, so that
the public can enjoy quality medical services nearby. However, due to the
impact of two lines of income and expenditure, unreasonable performance-based
pay, drug allocation restrictions and other factors, the implementation of the
hierarchical diagnosis and treatment system has little effect.[12-13] In September 2015, the State Council general office issued the guidelines on
promoting the construction of the hierarchical system "(Issued by the
State Council Office [2015] NO.70), points out that to establish the hierarchical
system is deepening medical and health system reform, to establish an important
content of basic medical and health care system with Chinese characteristics, has
been clear about the evaluation standard and the 2020 goals in 2017.In 2016, the
National Health and Family Planning Commission issued the Notice on the Pilot
Work of the Hierarchical Diagnosis and Treatment of Hypertension and Diabetes
(No. 1026 [2015] of the National Health Office), which defined the key tasks of
the hierarchical diagnosis and treatment of hypertension and diabetes, and
regarded its prevention and management as the breakthrough point to promote the
establishment of a new hierarchical diagnosis and treatment mode.In August 2016,
the CPC Central Committee and the State Council held the first National
Conference on Health and Health since the 21st century, and the hierarchical
diagnosis and treatment system ranked first among the five basic medical and
health systems.In April 2017, the General Office of the State Council issued
the Guiding Opinions on Promoting the Construction and Development of Medical
Consortium (Issued by the State Council Office [2017] No. 32), making it clear
that by the end of 2017, all tertiary hospitals in China will participate in
the construction of medical consortium. By the end of 2020, all secondary
hospitals and government-run primary medical and health institutions will
participate in the medical association.[12-13]
At this stage, the academic
community has increasingly in-depth research on the system of hierarchical
diagnosis and treatment. The number of journals published has increased from 48
in 2009 to 233 in 2018, with a nearly five-fold increase. Especially after 2015,
the annual research results have exceeded 100, which is related to the fact
that the hierarchical diagnosis and treatment has become the key to the success
or failure of the new medical reform and has been attached great importance to
at the national level."Combination of medical care", "basic
health care mechanism" and "medical service system" are cluster
words in this stage. A medical and health service system with clear functional
orientation and good cooperative relationship among institutions is the basis
for realizing hierarchical diagnosis and treatment.In order to effectively deal
with the aging problem, the combination of medical care and nursing care must
be supported by the hierarchical diagnosis and treatment. One of the key points
of the success of the hierarchical diagnosis and treatment is whether the
grassroots health service institutions can be revitalized.Have sprung up in
this stage, from the planned behavior theory, signal theory, system theory, grounded
theory, the social division of labor theory, stakeholder theory, game theory
and the theory of incentive compatibility, integration theory, bilateral
matching theory, platform, the Angle of theory, the expectancy theory of
couplet of hierarchical diagnosis and treatment of medical doctor two-way
referral behavior, family doctor contract mechanism, and two-way referral
factors such as research.Look from the research content, main from the supplier
(medical institutions), the buyer (patients, the masses) satisfaction, recognition
and its influencing factors, couplet of implementation path exploration, especially
in medical, family doctors to sign pattern more in-depth research, comparison
of diagnosis and treatment system at home and abroad, discusses hierarchical
diagnosis and to study the related system and mechanism to build
relationship;In terms of research methods, it is no longer limited to using
questionnaire survey, interview, empirical analysis, descriptive statistics and
other methods, but also adds operational research, econometrics and other
management engineering methods. In general, this period is more diversified in
terms of research theory, research content and research methods.
From the perspective of the
literature cited frequency, cited the highest amount is FuQiang[27] at the National institutes of health committee of the hospital management in
2016, published in the Chinese Health Economics titled “Strategic choice
for promoting hierarchical treatment model”, the paper published since the end
of July 2019 were cited 178 times, the inductive hierarchical system in foreign
countries mainly in a strict legal restriction, health service system that can
meet the needs of relying on, clear family and specialist professional
orientation, strict controls of diagnosis and treatment cost measures four
characteristics of strong, proposed our country establish hierarchical
diagnosis system is developed with focus on "at the grass-roots level
to" "can health care expenses" "patients really
benefit" three key issues, namely solve the problem of better medical
services, especially basic medical service supply and perfect related health
insurance and medical management policy to effectively guide and promote
medical service;
The second is Huang Bei[28],
from the outpatient department of Wuxi Second People's Hospital, whosepaper“Practice
and consideration on three types of medical alliance modes” published in Chinese
Hospital Management in 2015, which was cited for 147 times. Among the six
regional medical confederations in Wuxi City, the medical confederations of
Wuxi Second Hospital developed the earliest (from 2009 to 2014, it was a loose
regional medical confederations, and from 2015 to now, it has been exploring a
tight medical confederations), with relatively mature operation.
The article described the
author through to the Wuhan Fifth Hospital, Shanghai Jiao Tong University
School of Medicine Affiliated Ruijin Hospital, Wuxi Second People's
Hospitalmedical treatment alliance field interview and questionnaire survey, respectively
from the aspects of management system, running mechanism, and the results of
three different types of couplet of medical mode, found the three hospitals all
believed that community first treatment and two-way referral should be carried
out. It was pointed out that the appropriate type should be selected according
to the specific situation. The tight type direct regulation should be the first
choice if the relationship is relatively simple in the medical association, and
the loose type should be tried first if the relationship is complex.
From the perspective of the
number of papers published by authors, the top three were Zhang Liang (24
papers, Huazhong University of Science and Technology), Fang Peng-qian (15
papers, Huazhong University of Science and Technology), and Feng Ze-yong (13
papers, Chongqing Medical University).This stage Zhang Liang mainly focus in
the counties and townships on the two levels of medical service system, by
using the theory of integration, system thinking, collaborative division of
labor theory and stakeholder theory of interaction between the levels of
medical institutions, hierarchical diagnosis and "joining together of two
insurance" policy, classifying medical connotation and essential elements,
the key role of collaboration between counties and townships, counties and
townships medical service integration mechanism is studied.
Fang Peng-qian mainly focus
in public hospitals, using game theory and stakeholder theory to analyze the
construction of hierarchical diagnosis and treatment service system and the
first diagnosis at the grassroots level.It is the first time to build a
comprehensive hierarchical diagnosis and treatment evaluation system, to
discuss the construction of China's medical service system from the perspective
of foreign experience and China's county classification, and to consider the
relationship between "Medical care, medicine and medical insurance are
interconnected", hierarchical diagnosis and treatmentand medical
confederation.Feng Ze-yong mainly studies the relationship, influence and
effect between two-way referral, community first diagnosis and the multi-site
practice of doctors, essential medicine system, medical insurance system and
other related systems.
4 Conclusion
4.1 The increase speed of the
number of literatures is accelerated, but the research results need to be
further improved
1949-2019, our country the hierarchical
system overall present a trend of increasing number of research in the field of
literature, presents the blowout growth since 2015, the main and countries
since 2015 to the hierarchical system as an important driving force of
deepening reform and intensify efforts to promote, as the "healthy China
2030" plan is put forward, and the hierarchical system will be the key reform
direction in the future, is also much starker choices-and graver
consequences-in planning a system comprehensive strategic deployment, the hierarchical
system of related research number will be showed a trend of sustained and rapid
growth in the next ten years.Among SCI sources, EI sources, Peking University
Chinese core journals, CSSCI and CSCD journals, more than half of the research
results are from Peking University Chinese core journals, which to some extent
reflects the need to further strengthen and improve the authority and influence
of the research results of China's hierarchical medical system.
4.2 There is a lot of
cooperation among institutions, but the cooperation and communication among
authors is limited, and no stable core group of authors has been formed
The hierarchical system
research field in our country Formed the four major institutions of cooperation,
although less communication between agencies group, but in college as the main
body, cross-regional and health administrative organization (government actors)
and the government research institutes, medical research institutions such as
the cooperation and communication of broke the traditional disciplinary
boundaries, benefit to the progress of the hierarchical system research and development;
At present, a group of authors with Zhang Liang, Fang Pengqian, Lu Zuxun, Wang
Chaoxin, Zhuo Lang and Liang Hong as the core is basically formed in the
domestic research. The cooperation within the group is mostly in the mode of
tutor-guided cooperation. The cooperation and communication among the authors
is relatively loose, and the region is limited to Hubei Province, Shanghai and
Xuzhou City, with less cross-regional cooperation. The total number of
published papers by core authors calculated by Price's law accounts for less
than half of the total number of literatures, indicating that a stable core
group of authors has not been formed in the research field of hierarchical
diagnosis and treatment in China.
4.3 Research hotspots are
gradually diversified and research directions are continuously refined
From the point of the
evolution, hierarchical system of diagnosis and treatment of research in China
has experienced the planned economy period in the three major health care under
the control of "blocks hierarchical division of medical service
system", appeared in the early years of the reform and opening up loose
and new exploration period, the new health care reform is put forward with the
period a total of three stages, after a "community health service"
couplet of "medical" "impact factor" "all-around
doctor" "effect appraisal" hot word "medical service
system" and so on and highlight the key words, the research direction is
more diverse, refining, there are a lot of groundbreaking research.
4.4 Future Prospects
In general, the
hierarchical diagnosis and treatment system has experienced nearly 70 years of
evolution and has attracted great attention since 2015, which is closely
related to the importance of the country, the doctor-patient problems facing
China today, and the people's livelihood issues. In terms of research results, from
the perspective of theoretical research, some scholars put forward integration
theory, synergistic effect, stakeholders, Pareto efficiency, game theory, halo
effect and so on to explain and improve the system, but there is still a lack
of deeper research and innovation in the management concept. From the
perspective of the practice research of scholars around the study paths, supply
and demand both sides will, recognition of investigation and study, from lack
of practice deepening the research on to more specific aspects of the system, and
clarifying the hierarchical system and basic medical insurance system, the
basic drug system, relevant relations between system problems such as reform of
public hospitals. The concept of hierarchical diagnosis and treatment has been
advocated since the early days of the founding of the People's Republic of
China. It has been nearly 70 years since then. How to find a new innovation path
from the system level through closer communication and cooperation is a problem
worth studying.
