关键词: 分级诊疗, 病人转诊, 社区卫生服务, 社区卫生中心, 全科医生, 城郊差异

Abstract: Background　Realizing successful bi-directional referrals is an essential target of the comprehensive medical reform for public hospitals launched in 2009 in China. Bi-directional referrals in urban and suburban areas are different due to domestic uneven distribution of health resources，and administrative regional differences of medical and human resources as well as disease management. It is of great significance to understand bi-directional referrals in urban and suburban areas to maximize the utilization of health resources. Objective　To perform a comparative analysis of bi-directional referrals in urban and suburban community health centers（CHCs） in Shanghai with reasonable suggestions proposed，providing a practical and reliable reference for better promoting such services in Shanghai. Methods　From November to December 2018，244 administrators and 4 047 general practitioners（GPs） were enrolled from 244 CHCs in 16 districts of Shanghai. A survey was conducted among the administrators using a self-developed questionnaire（for administrators） for collecting their demographic data，and their perceptions of organizational mechanism，process and results of referrals. And another survey was conducted in the GPs using a self-developed questionnaire（for GPs） for collecting the data about demographics，modes of bi-directional referrals and contact ways for upward referrals used，prevalence of filling the referral information except the referral form，and prevalence of communicating with physicians in the higher level hospital when receiving the downward referred patient. Results　The two surveys achieved response rates of 100.00% （244/244） and 96.98%（3 925/4 047），respectively. Of the 3 925 GP respondents，2 641（32.71%） worked in suburbs and 1 284（67.29%） in urban areas. There were significant differences in gender ratio，distribution of title and working years between urban and suburban GPs（P<0.05）. Of the CHCs，97.54%（238/244） established a bi-directional referral system，and 89.34%（218/244） signed a bi-directional referral agreement with secondary and tertiary hospitals. There are significant differences between urban and suburban CHCs in having a worker of communications for bi-directional referrals，setting up bi-directional referral files，reserving beds for downward referred patients，network connections for bi-directional referrals，peer-to-peer communication with corresponding experts or departments，and communication with the worker responsible for bi-directional referrals in higher level hospitals（P<0.05）. 50.41%（123/244） of the CHCs had less than 100 upward referrals and 75.00%（183/244） had less than 10 downward referrals per month. There was a significant difference in the average number of upward referrals per month between urban and suburban CHCs（P<0.05）.Conclusion　Shanghai's urban and suburban CHCs have many differences in bi-directional referrals，which are composed of mainly upward referrals. To improve the development of bi-directional referral system，it is suggested to improve the construction of suburban community health services，establish a health record-based bi-directional referral platform using the Internet technologies plus favorable recommendations，and actively establishing regional medical groups.

Key words: Hierarchical medical system, Patient transfer, Community health services, Community health centers, General practitioner, Urban-rural disparity