Status and Associated Factors of Patients' Behaviors of Seeking Community-based Outpatient Services after the Comprehensive Medical Reform of Separating Drug Sales from Medical Treatment Launched in Beijing, 2017

doi:10.12114/j.issn.1007-9572.2019.01.006

Abstract

Abstract: Background　On April 8，2017，a new medical reform was launched officially in Beijing. According to the regulations of the reform，the gap in medical service fees of different levels of medical institutions is widened appropriately，aiming to promote the development of hierarchical diagnosis and treatment by guiding the patients to seek healthcare rationally via the pricing leverage. However，there are no studies concerning the effect of the implementation of the medical reform in this city on patients' healthcare-seeking behaviors from patients' perspective.Objective　To evaluate the effect of the medical reform launched in Beijing in 2017 on improving the hierarchical diagnosis and treatment status.Methods　This survey was conducted in 2 100 typically sampled outpatients from seven community health stations/centers in Yanshan area in Beijing's Fangshan District from November 20 to December 5，2017，with a self-developed questionnaire for collecting demographic characteristics of society，the changes in the choice of healthcare institution，awareness of the services delivered by the community healthcare setting after the medical reform launched in Beijing in 2017，awareness of the policies concerning the reform，and the prevalence of chronic disease.Results　Totaled 2 077 questionnaires were returned，with a 98.90% response rate.The preferred institution for initial treatment differed significantly before and after the reform （χ2=74.349，P<0.05），as did the preferred institution for the retreatment of chronic diseases （χ2=255.112，P<0.05）． Among the respondents who preferred to choose a tertiary hospital in Fangshan District for initial treatment before the reform，15.12%（314/2 077） sought initial treatment in a community healthcare setting after the reform.Of those who preferred to choose a tertiary hospital in Fangshan District for the retreatment of chronic diseases before the reform，21.62%（449/2 077） sought retreatment in a community healthcare setting after the reform.Multivariate Logistic regression analysis showed that educational level，average monthly household income，level of awareness of the services delivered by the community healthcare settings，seeking healthcare in community healthcare settings being more convenient than in hospitals were associated with the changes in the institution for initial treatment（from a tertiary hospital to a community healthcare setting）；average monthly household income，level of awareness of the services delivered by the community healthcare settings，and suffering from chronic diseases were associated with the changes in the institution for the retreatment of chronic diseases（from a tertiary hospital to a community healthcare setting）． After the reform，80.74%（1 677/2 077） of the respondents demonstrated no reduction in the number of hospital visits although the registration fee increased，15.07%（313/2 077） prescribed drugs less frequently，and 11.22%（233/2 077） showed a decrease in the average monthly medical costs.Conclusion　Since 2017 the medical reform has been carried out，many patients who preferred to seek healthcare in tertiary hospitals before the reform go to community healthcare settings for care，but a few patients who preferred to seek healthcare in community healthcare settings before the reform go to the tertiary hospitals for care.The changes in the institution for treatment（from a tertiary hospital to a community healthcare setting） more frequently occur in those seeking retreatment for chronic diseases compared with those seeking initial treatment.Socioeconomic status，level of awareness of the services delivered by community healthcare settings，level of convenience in seeking healthcare in community healthcare settings，and suffering from chronic diseases are associated with the changes in the institution for treatment（from a tertiary hospital to a community healthcare setting）． Patients' medical burden has not been affected much by the reform.The insufficiency of medicines in community healthcare settings has made some patients give up seeking healthcare in such institutions.

Key words: Comprehensive reform of separation of medicine, Outpatient, Health seeking behavior, Grading diagnosis and treatment, Community health services, Root cause analysis, Beijing

摘要： 背景　2017-04-08北京市正式实施新医改，不同级别医疗机构医事服务费适当拉开价格差距，目的是实现利用价格杠杆引导患者合理分级诊疗，但是尚未有研究从需方的角度分析北京市新医改对患者就医行为的影响。目的　了解北京市医药分开综合改革后社区门诊患者的就医行为变化及其影响因素，评价医药分开综合改革促进分级诊疗的效果。方法　采用典型调查方法，对2017-11-20至2017-12-05在燕山地区7个社区卫生服务中心（站）就医的2 100例门诊患者进行问卷调查，调查内容包括社会人口学特征、医药分开综合改革后就医行为变化、政策及服务知晓情况等。结果　调查回收有效问卷2 077份，问卷回收有效率为98.90%。医药分开综合改革前后社区门诊患者预期首诊机构和预期慢性病复诊机构的差异具有统计学意义（χ2=74.349，P<0.05；χ2=255.112，P<0.05）。社区门诊患者中医药分开综合改革后预期首诊机构由房山区三级医院变为社区医疗机构的患者占15.12%（314/2 077），预期慢性病复诊机构由房山区三级医院变为社区医疗机构的患者占21.62%（449/2 077）。多因素Logistic回归分析结果显示，受教育程度、家庭月总收入、社区卫生服务项目了解程度、社区就医比到医院方便程度是患者医药分开综合改革后从区三级医院下沉到社区首诊的影响因素（P<0.05）；家庭月总收入、是否患慢性病、社区卫生服务项目了解程度是患者医药分开综合改革后从区三级医院下沉到社区慢性病复诊的影响因素（P<0.05）。社区门诊患者中没有因挂号费上涨而减少到医院看病次数的患者占80.74%（1 677/2 077）、开药频率与医药分开综合改革前相比减少的患者占15.07%（313/2 077），医药分开综合改革后月医疗支出减少的患者占11.22%（233/2 077）。结论　北京市医药分开综合改革促进了患者下沉到社区医疗机构就医，但少量患者回流到三级医院就医；就医机构的转变主要为从三级医院到社区医疗机构，社区患者慢性病复诊机构的转变比疾病首诊机构的转变更加明显；社会经济状况、社区卫生服务项目知晓情况、社区就医方便程度和患有慢性病影响患者从三级医院下沉到社区就医。医药分开综合改革后社区患者就医负担变化不大，社区药物不全问题影响患者下沉到社区就医。

关键词: 医药分开综合改革, 门诊病人, 就医行为, 分级诊疗, 社区卫生服务, 影响因素分析, 北京

DAI Yunhe,WANG Tao,YU Hongxia, et al. Status and Associated Factors of Patients' Behaviors of Seeking Community-based Outpatient Services after the Comprehensive Medical Reform of Separating Drug Sales from Medical Treatment Launched in Beijing, 2017　[J]. Chinese General Practice, 2019, 22(1): 24-31. DOI: 10.12114/j.issn.1007-9572.2019.01.006.
戴云鹤,王涛,俞红霞等. 北京市医药分开综合改革后社区门诊患者的就医行为及影响因素研究[J]. 中国全科医学, 2019, 22(1): 24-31. DOI: 10.12114/j.issn.1007-9572.2019.01.006.

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