Abstract: Background Multiple chronic diseases have become an important characteristic of the development of chronic diseases，the chronic disease response method based on community health services has been recognized as one of the most cost-effective solutions，the quality of community health services affects the well-being of the public. Ratchet effect is beneficial for behavioral research，and we can provide useful reference for the evaluation of community health service quality for patients with multiple chronic diseases based on the perspective of doctor-patient behavior. Objective Research on the influencing factors of community health service' quality evaluation for patients with multiple chronic diseases based on ratchet effect. Methods Using multi-stage sampling method to select patients with multiple chronic diseases as the research subjects from 18 communities in Guangzhou，Guangdong Province，during July to August 2023. The community health service quality assessment questionnaire was used the PCAT scale developed by the Johns Hopkins Primary Care Center in the United States. Exploring the impact on the evaluation of community health service quality for patients with multiple chronic diseases under the moderation effect of medical insurance by constructing a multiple linear regression model. Results We included 282 subjects with 129 males and 153 females，their average age was（38.0±8.0） years old. Married accounted for the majority of the participants，with 165 （58.51%）；local residents predominated，with 215 individuals（76.24%）；The distribution of educational backgrounds was balanced，with postgraduates constituting the largest group：112 individuals（39.73%）；The majority of residents' monthly income were below 5，000 yuan，with 163 individuals（57.80%）；A total of 242 participants（85.81%）reported their health status as good or very good；The majority of participants were covered by public healthcare，urban employee social insurance，and urban resident social insurance，with 239 individuals（84.75%）. The PCAT score for patients with multiple chronic conditions was（104.47±13.63）points. Statistically significant differences（P<0.05）were observed in PCAT scores based on different monthly income levels and health statuses. There was a statistically significant difference（P<0.05）in PCAT among institutions which had two levels of familiarity with multiple chronic diseases' patients，and the same for variations in willingness to utilize primary care services. Medical insurance had a positive moderating effect on the evaluation of community health service quality for patients with multiple chronic diseases（P<0.05）. The behavior indicators of doctor-patient relationship had a ratchet effect on the evaluation of community health service quality for patients with multiple chronic diseases. That is to say，the higher the familiarity of community health service institutions with patients with multiple chronic diseases and the stronger the intention of patients with multiple chronic diseases to seek medical treatment at the grassroots level，the higher the evaluation of the quality of community health services for patients with multiple chronic diseases，it showed a phenomenon of only increasing without decreasing. Conclusion Medical insurance can enhance the evaluation of community health service quality by patients with multiple chronic conditions. The state should continue to introduce beneficial policies for improving the patients' medical experience. At the same time，we should advocate for the establishment of effective two-way communication between doctors and patients. Furthermore，we should continue to strengthen the awareness of primary care for patients with multiple chronic diseases.

Key words: Chronic disease, Community health services, Quality evaluation, Multiple chronic diseases, Ratchet effect

摘要： 背景 多重慢性病已成为慢性病进展的重要特征，以社区卫生服务为基础的慢性病应对方式已被公认为最具成本效益的解决方案之一，社区卫生服务质量直接影响多重慢性病患者诊疗效果。棘轮效应有利于行为学研究，为基于医患行为视角进行多重慢性病患者社区卫生服务质量评价研究提供有益参考。目的 探究基于棘轮效应的多重慢性病患者对社区卫生服务质量评价的影响因素。方法 本研究用多阶段抽样的方法，于2023年7—8月在广东省广州市18个社区中选取符合条件的多重慢性病患者为研究对象。采用美国约翰霍普金斯大学初级保健中心开发的PCAT量表进行社区卫生服务质量评价问卷调查。构建多元线性回归模型，探讨在医保调节作用下，基于棘轮效应对多重慢性病患者社区卫生服务质量评价的影响和程度。结果 共纳入研究对象282名，其中男129名，女153名；平均年龄（38.0±8.0）岁；已婚者居多，165名（58.51%）；本地居民为主，具有本地户籍者215名（76.24%）；文化程度分布均衡，研究生学历最多，112名（39.73%）；大部分居民平均月收入在5000元以下，163名（57.80%）；自评健康状况为比较好及很好者242名（85.81%）；绝大多数享有着公费医疗、城市职工社会保险和城市居民社会保险，239名（84.75%）。多重慢性病患者PCAT量表得分为（104.47±13.63）分，不同月收入、健康状况的多重慢性病患者PCAT量表得分比较，差异有统计学意义（P<0.05）；社区卫生服务机构对多重慢病患者的不同熟悉度对患者PCAT量表得分比较，差异有统计学意义（P<0.05）；不同基层就诊意向的多重慢性病患者PCAT量表得分比较，差异有统计学意义（P<0.05）；医保对多重慢性病患者的社区卫生服务质量评价有正向调节作用（P<0.05）；在医保调节作用下，医患医疗行为指标对多重慢性病患者的社区卫生服务质量评价存在棘轮效应，即社区卫生服务机构对多重慢性病患者的熟悉度越高、多重慢性病患者基层就诊意向越强，则多重慢性病患者的社区卫生服务质量评价高，且呈现只上升不下降的现象。结论 医保能提升多重慢病患者对社区卫生服务质量的评价，国家应继续出台惠民的医保政策，提升多重慢病患者就医体验；同时呼吁医患双向有效沟通的建立；此外，应继续强化多重慢病患者的基层首诊意识。

关键词: 慢性病, 社区卫生服务, 质量评价, 多重慢性病, 棘轮效应