Abstract: Background　Bi-directional referrals have been carried out nationwide，but there are still problems during the implementation，such as unsuccessful referrals，easy implementation of upward referrals but difficult implementation of downward referrals，and bi-directional referrals almost becoming unidirectional referrals.Understanding the status of bi-directional referrals and influencing factors in community-dwelling residents greatly promotes the improvement of the bi-directional referral system.Objective　To investigate bi-directional referrals and influencing factors in community-dwelling residents in Haidian District，Beijing，providing evidence for the development of referral programs and policies for the medical consortium.Methods　A combination of quantitative and qualitative research methods is used.Quantitative research is divided into two parts.The first part is about the statistic analysis of number of patients transferred from lower level hospitals and related department data provided by Appointment and Referral Center，Peking University Third Hospital.The second part is about the analysis of the results（including basic socio-demographic data，referral experience and influencing factors） of a survey〔achieving a response rate of 91.2%（547/600）〕conducted with a self-developed questionnaire among community-dwelling residents with referral experience from February to June 2018 in the Peking University Third Hospital Medical Consortium，Haidian District，Beijing.The qualitative research was based on individual interviews with a outpatient department leader，2 doctors，and 2 doctors from a core hospital，a tertiary hospital，and a primary care hospital in a regional medical consortium，respectively，and 10 community-dwelling residents with referral experience in the regional medical consortium.Results　In the medical consortium，the number of patients transferred upwardly increased by 2 507 in 2016 compared with 2014，with an increase rate of 106.5%.But that decreased in 2017 compared with 2016.Among the 547 respondents，474（86.7%） experienced upward referral，106（19.4%） experienced downward referral，and 33（6.0%） experienced bi-directional referrals.The main reason for upward referral reported by most respondents（73.0%） was high level of diagnosis and treatment in the tertiary hospital.Age，monthly income，education level and type of medical insurance were associated with upward referral（P<0.05）.The main reason for downward referral reported by most respondents（51.9%） was short distance between their home and the hospital.Monthly income and awareness level of bi-directional referrals were associated with downward referral（P<0.05）.Qualitative interviews showed that major facilitators to residents' referral behaviors were referrals meeting the healthcare needs，and referrals being convenient for healthcare seeking.And the major barriers to residents' referral behaviors were insufficient publicity of the service capacity of primary care institutions and poor service delivery initiative in primary care doctors.Conclusion　The development of bi-directional referral in the regional medical consortium shows a good trend since it has been implemented，but it is far from perfect.In order to better implement the bi-directional referral system and policies，it is suggested to increase inputs to primary care institutions，improve residentsh awareness level of bi-directional referral，and build departments with competitive advantages in primary care institutions.

Key words: Patient transfer, Community health services, Regional medical consortium, Root cause analysis, Beijing

摘要： 背景　双向转诊已在全国范围内开展，但目前仍存在转诊不畅、上转易下转难、单向转诊等问题，了解社区居民双向转诊现状及影响因素对于进一步完善双向转诊制度具有重要意义。目的　了解北京市海淀区社区居民双向转诊现状，分析社区居民双向转诊行为影响因素，为医联体制定转诊方案和政策提供依据。方法　采用量性研究和质性研究相结合的方法。量性研究分两部分，第一部分对北京大学第三医院转诊预约中心提供的上转人数及科室相关数据进行统计；第二部分选取2018年2—6月在北京市海淀区北医三院医联体有转诊经历的社区居民进行问卷调查，调查问卷自行设计，主要包括社区居民基本情况、转诊经历及影响因素等内容。共发放问卷600份，回收547份，问卷有效回收率为91.2%。质性研究选取1例医联体核心医院门诊部领导、2例三级医院医生、2例基层医生、10例有转诊经历的社区居民进行访谈。结果　2014—2016年，医联体上转人数增加2 507例，增幅为106.5%，2017年上转人数较2016年有所下降。547例社区居民中，474例（86.7%）有上转经历，106例（19.4%）有下转经历，33例（6.0%）有双向转诊经历。居民上转最主要的原因为认为三级医院诊疗水平高（73.0%），年龄、月收入、文化程度和医保类型是居民上转的影响因素（P<0.05）；下转最主要的原因为离家近（51.9%），月收入、是否了解双向转诊是居民下转的影响因素（P<0.05）。质性访谈结果显示促进居民转诊行为的因素主要有满足转诊居民需要和转诊方便居民就医，阻碍居民转诊行为的因素主要有基层宣传力度不足和基层医生主观能动性较差。结论　实施双向转诊以来，北京市海淀区医联体在转诊方面总体呈良好发展趋势，但尚未实现真正意义的双向转诊。为贯彻落实医联体双向转诊政策，可从加大基层医院投入、提高居民双向转诊的认知水平、建设基层医院优势科室等方面进一步完善双向转诊制度。

关键词: 病人转诊, 社区卫生服务, 医联体, 影响因素分析, 北京