Implementation Effect of the "1+1+1" Type of Contract on the Development of Family Doctor Services　#br#

doi:10.12114/j.issn.1007-9572.2018.31.007

Abstract

Abstract: Objective　To assess the implementation effect of the "1+1+1" type of contract on the development of family doctor services，offering suggestions for further development of such services.Methods　From the electronic patient information system of Pudong New Area Datuan Community Health Center （PNADCHC），we sampled 6 390 community-dwelling residents who received the contracted "1+1+1" type of family doctor services，and reviewed the registered data of these residents concerning demographic characteristics，and selected district/municipal-level medical institutions for treatment，number and costs of visits to PNADCHC and the family doctor，use of initial healthcare services，dispensation of drugs for chronic conditions and referrals，and the assessment of the quality of family doctor services before and after receiving the contracted "1+1+1" type of family doctor services.Results　Compared with before receiving the contracted "1+1+1" type of family doctor services，after receiving such services，the participants demonstrated a higher ratio of number of visits to the family doctor to the number of visits to PNADCHC〔60.21% （66 901/111 120） vs 43.07%（47 891/111 204），χ2=22.328，P<0.001〕，an indistinctively changed median value of visits to PNADCHC〔15（25） vs 15（24）〕（Z=0.048，P=0.967），a higher median value of visits to the family doctor 〔9（16） vs 7（14），Z=24.641，P<0.001〕，spent less median annual medical costs 〔2 018.8（4 398.7）yuan vs 2 247.8（4 911.4）yuan，Z=10.542，P<0.001〕，and showed significant changes in the institutions selected for initial treatment，dispensation of drugs for chronic conditions and referrals （P<0.05），and presented higher ratios of seeking initial treatment and dispensation of drugs for chronic conditions in PNADCHC，and being transferred to district- or municipal-level hospitals or transferred to PNADCHC （P<0.05）．Moreover，they also displayed lower rates of receiving antibiotic prescriptions and fluid replacement in the clinic，but a higher rate of receiving rational antibiotic treatment（P<0.05）．Conclusion　The implementation of the contracted "1+1+1" type of family doctor services is conducive to the establishment of a stable family physician-patient relationship，development of hierarchical diagnosis and treatment，effective use of family doctor services，control of medical costs，amelioration of the healthcare-seeking behaviors and the improvement of the quality of family doctor services，so it is recommended to be promoted in community health centers.

Key words: Combination signing, Family doctor services, Service effect

摘要： 目的　探讨“1+1+1”组合签约对家庭医生服务效果的影响，为下一步家庭医生工作提出建议。方法　选取2017年大团社区卫生服务中心医院信息系统中与家庭医生进行“1+1+1”组合签约的6 390例社区居民为研究对象。在大团社区卫生中心医院信息系统中调阅组合签约前后家庭医生服务效果信息（包括组合签约居民基本情况和选择区/市级医疗机构情况，在社区卫生服务中心和家庭医生处就诊的次数及医疗费用，首诊服务、慢性病配药服务及转诊服务利用情况，家庭医生服务质量），并进行比较。结果　组合签约后大团社区卫生服务中心在家庭医生处就诊次数在中心就诊次数中占比高于组合签约前，差异有统计学意义〔60.21%（66 901/111 120）比43.07%（47 891/111 204），χ2=22.328，P<0.001〕。组合签约前后在大团社区卫生服务中心居民中位就诊次数分别为15（25）、15（24）次，两者比较，差异无统计学意义（Z=0.048，P=0.967）；组合签约后居民家庭医生处中位就诊次数高于组合签约前，差异有统计学意义〔9（16）次比7（14）次，Z=24.641，P<0.001〕。组合签约后居民中位年医疗费用低于组合签约前，差异有统计学意义〔2 018.8（4 398.7）元比2 247.8（4 911.4）元，Z=10.542，P<0.001〕。签约前后社区居民首诊机构选择、慢性病配药机构选择、转诊机构选择比较，差异有统计学意义（P<0.05）。组合签约后选择社区卫生服务中心为首诊机构及慢性病配药机构者占比、选择上转至区/市级医疗机构及转回社区卫生服务中心者占比高于组合签约前，差异有统计学意义（P<0.05）。组合签约后抗生素处方占比、门诊补液占比低于组合签约前，合理使用抗生素占比高于组合签约前，差异有统计学意义（P<0.05）。结论　家庭医生开展“1+1+1”组合签约工作，建立稳定契约关系，提供分级诊疗服务，在提高家庭医生有效利用率、控制医疗费用、影响就医行为、提高家庭医生服务质量方面具有重要的作用，在社区卫生服务中心家庭医生制工作中应加以推广。

关键词: 组合签约, 家庭医生服务, 服务效果

CAI Liqiang,HOU Jin. Implementation Effect of the "1+1+1" Type of Contract on the Development of Family Doctor Services　#br#[J]. Chinese General Practice, 2018, 21(31): 3814-3817. DOI: 10.12114/j.issn.1007-9572.2018.31.007.
蔡利强,侯进. “1+1+1”组合签约对家庭医生服务效果的影响研究[J]. 中国全科医学, 2018, 21(31): 3814-3817. DOI: 10.12114/j.issn.1007-9572.2018.31.007.

References

［1］上海卫生和计划生育委员会.关于进一步推进本市社区卫生服务综合改革与发展的指导意见［Z］．2015.
［2］秦江梅，张丽芳，林春梅，等．我国基层卫生综合改革进展［J］．中国全科医学，2017，20（22）：2683-2690．DOI：10.3969/j.issn.1007-9572.2017.22.001.
QIN J M，ZHANG L F，LIN C M，et al．Progress of comprehensive reform of primary health care in China［J］．Chinese General Practice，2017，20（22）：2683-2690．DOI：10.3969/j.issn.1007-9572.2017.22.001.
［3］芦炜，张宜民，梁鸿，等．基于需方的家庭医生签约服务实施效果评价：以慢性病为重点［J］．中国卫生政策研究，2016，9（8）：23-30．DOI：10.3969/j.issn.1674-2982.2016.08.005.
LU W，ZHANG Y M，LIANG H，et al．The performance evaluation based on the demand side of the family doctor contract service：a focus on chronic diseases［J］．Chinese Journal of Health Policy，2016，9（8）：23-30．DOI：10.3969/j.issn.1674-2982.2016.08.005.
［4］彭志强，唐燕飞，刘秋英.中山市大涌镇青岗社区家庭医生服务签约情况及有效签约方式探讨［J］．中国全科医学，2017，20（33）：4100-4104．DOI：10.3969/j.issn.1007-9572.2017.00.139.
PENG Z Q，TANG Y F，LIU Q Y.Current situation of family doctor services in Qinggang Community of Dayong Town，Zhongshan City and the effective methods of signing a contract with family doctors［J］．Chinese General Practice，2017，20（33）：4100-4104．DOI：10.3969/j.issn.1007-9572.2017.00.139.
［5］肖筱，袁立，周昌明，等．推行家庭医生签约对社区卫生服务利用的影响［J］．中国卫生资源，2015，18（1）：64-67．DOI：10.13688/j.cnki.chr.2015.14158.
XIAO X，YUAN L，ZHOU C M，et al．Inlfuence of family physician contract services on utilization of community health services［J］．Chinese Health Resources，2015，18（1）：64-67．DOI：10.13688/j.cnki.chr.2015.14158.
［6］刘荣，孙瑛，金岚，等．上海市龙柏社区家庭医生签约服务状况及影响因素分析［J］．护理研究，2014，28（35）：4460-4461．DOI：10.3969/j.issn.10096493.2014.035.054.
LIU R，SUN Y，JIN L，et al．Analysis of status of family doctor contracted services in Longbai Community of Shanghai City and its influencing factors［J］．Chinese Nursing Research，2014，28（35）：4460-4461．DOI：10.3969/j.issn.10096493.2014.035.054.
［7］刘春平，陈添华，郑敏，等．海南省家庭医生签约服务开展现状及发展建议研究［J］．中国全科医学，2017，20（34）：4248-4252．DOI：10.3969/j.issn.1007-9572.2017.34.007.
LIU C P，CHEN T H，ZHENG M，et al．Current situation and development suggestions of family doctors' contract-signing services in Hainan Province［J］．Chinese General Practice，2017，20（34）：4248-4252．DOI：10.3969/j.issn.1007-9572.2017.34.007.
［8］张玮.开展家庭医生制服务的可行性分析与对策研究［J］．中国全科医学，2011，14（19）：2136-2138．DOI：10.3969/j.issn.1007-9572.2011.19.006.
ZHANG W.Feasibility of implementing family doctor service and the countermeasures［J］．Chinese General Practice，2011，14（19）：2136-2138．DOI：10.3969/j.issn.1007-9572.2011.19.006.
［9］范素芳，于永娟.加快推进分级诊疗制度建设的对策研究［J］．中国农村卫生事业管理，2015，35（4）：412-414.
FAN S F，YU Y J.Strategies for improving hierarchical diagnosis and treatment system［J］．Chinese Rural Health Service Administration，2015，35（4）：412-414.

[1]	YIN Zhaoxia, KONG Chongyu, ZOU Xianhui, LI Chuang, HUANG Yin, FENG Yang, WANG Yunfei, GONG Weijie. Traditional Chinese Medicine Disease Spectrum Analysis in Outpatient Clinics of Contracted Residents by Family Doctors in Shenzhen Community Health Service Centers [J]. Chinese General Practice, 2023, 26(25): 3112-3117.
[2]	GUO Yahong, GUO Haoqian, NING Yanhua, JIANG Ting, LI Meiman, LYU Xiongxiong, KONG Weijuan, LIU Haiyan. Construction of "Internet+" Family Nursing Management Model for the Elderly Based on Contracted Family Doctor Services [J]. Chinese General Practice, 2023, 26(23): 2876-2881.
[3]	ZHAO Linlin, SHAO Shuang, LUO Qi, CHEN Xiaolei, DU Juan. Practice Strategy of Treatment-prevention Integration of Family Doctor Team in China [J]. Chinese General Practice, 2023, 26(22): 2715-2719.
[4]	XU Jiayu, YAN Hua, FANG Junbo, WANG Haiqin, GUO Pei, SHEN Fulai, WANG Xingsong. Standardized Workload-based Analysis of the Services Delivered by a Family Doctor Team in a Community Health Institution [J]. Chinese General Practice, 2023, 26(13): 1641-1647.
[5]	MA Zhiqiang, WU Xianglan. The Doctor-patient Trust in General Practice Service and Its Countermeasure Suggestions Based on Trusted Source Model [J]. Chinese General Practice, 2023, 26(10): 1172-1178.
[6]	MENG Wenqi, LIU Songyi, JIANG Xiaoli, PENG Haibo, LI Zixin, YU Qianqian, YIN Wenqiang, SUN Kui, CHEN Zhongming, GUO Hongwei. Mechanisms Affecting the Effectiveness of Contracted Family Doctor Services: a Grounded Theory Analysis [J]. Chinese General Practice, 2023, 26(10): 1192-1197.
[7]	LI Xinyan, HAN Youli. Effects and Implications of Introducing Competition Mechanisms in the Delivery of Contracted Family Doctor Services [J]. Chinese General Practice, 2023, 26(04): 447-452,459.
[8]	MA Zhiqiang, ZHANG Baoli, GUO Le. Development, Reliability and Validity of the General Practitioner Competency Rating Scale for Assessing General Practitioners' Competencies in Delivering Contracted Healthcare Services [J]. Chinese General Practice, 2023, 26(04): 477-485.
[9]	XU Pingping, ZHAO Jing, LI Chunxiao, LI Linfeng, LIU Senyuan. Quantitative Evaluation of Chinese Central Government's Family Doctor Contract Service Policy Based on PMC Index Model [J]. Chinese General Practice, 2023, 26(04): 440-446.
[10]	MA Zhiqiang, GUO Le, LI Zhao, GE Bailin. Development of the General Practitioner Competency Model Using Grounded Theory for Assessing General Practitioners' Competencies in Delivering Contracted Care Services [J]. Chinese General Practice, 2023, 26(04): 460-466,485.
[11]	LIU Zhimin, FENG Lei. Content Analysis and Optimization Path Exploration of Family Doctors' Contracting Service Agreements [J]. Chinese General Practice, 2023, 26(04): 453-459.
[12]	LIU Songyi, MENG Wenqi, PENG Haibo, JIANG Xiaoli, LI Zixin, YU Qianqian, YIN Wenqiang, CHEN Zhongming, SUN Kui, GUO Hongwei. Contracted Residents' Evaluation for Continuity of Contracted Family Doctor Services and Influencing Factors [J]. Chinese General Practice, 2022, 25(34): 4312-4317.
[13]	Gang YAO, Cheng ZHANG, Jian XU, Wenlei PAN, Chen CHEN, Min ZHU, Zhaoxin WANG, Jiaoling HUANG. Needs and Associated Factors of Contracted Family Doctor Services in Young and Middle-aged Office Building Occupants [J]. Chinese General Practice, 2022, 25(22): 2773-2781.
[14]	Jian XU, Gang YAO, Wenlei PAN, Fangfang DAI, Qian HUANG, Rui LIU, Xin LI, Liang ZHOU, Jiaoling HUANG. Prevalence of Met Needs for Contracted Family Doctor Services and Associated Factors in Young and Middle-aged Office Building Occupants [J]. Chinese General Practice, 2022, 25(22): 2782-2789.
[15]	Wenlei PAN, Yongqing XU, Xiao LYU, Jian XU, Gang YAO, Jie SHAO, Rui LIU, Xin LI, Jianwei SHI, Jiaoling HUAGN. Anxiety Prevalence and Influencing Factors in Young and Middle-aged Office Building Occupants [J]. Chinese General Practice, 2022, 25(22): 2790-2795.