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

摘要： 背景　当前医疗改革的大背景下，双向转诊是公立医院综合改革的基本目标之一。由于我国卫生资源分布不均，不同行政区在医疗资源、人力资源分布及诊疗管理上存在诸多差异，导致城区与郊区双向转诊情况不尽相同。了解城区与郊区的双向转诊情况对于更好实现资源利用最大化有重要意义。目的　调查分析上海市城市与郊区社区卫生服务中心双向转诊开展实施现况，发现二者差异，并提出合理化建议，为上海市更好地推行双向转诊提供切实可靠的参考依据。方法　于2018年11—12月，选取涵盖上海市16个行政区的244家社区卫生服务中心的行政负责人及4 047例全科医生进行问卷调查。对行政管理人员调查的主要内容包括基本情况和双向转诊的组织机制、过程、转诊效果情况；对全科医生调查的主要内容包括基本情况和双向转诊方式、上转转诊联系方式、是否填写除转诊单之外的转诊信息、接收下转患者时是否与上级医生保持联络等。结果　共发放社区行政管理问卷244份，回收有效问卷244份，问卷有效回收率100.00%；共发放全科医师问卷4 047份，回收有效问卷3 925份，有效回收率96.98%。3 925例全科医生中，在郊区工作2 641例（32.71%），在城区工作1 284例（67.29%）。城市和郊区全科医生性别、职称、工作年限比较，差异有统计学意义（P<0.05）。97.54%（238/244）的社区卫生服务中心建立了双向转诊制度，89.34%（218/244）的社区卫生服务中心与二三级医院签订了双向转诊协议。城区与郊区社区卫生服务中心在设立双向转诊专门联络负责人、建立双向转诊档案、专门设置预留床位保证接收下转患者、双向转诊方式中的网络联系、点对点与相应专家或科室联系、与相应上级医院负责双向转诊的专门联系人联系等方面比较，差异有统计学意义（P<0.05）。50.41%（123/244）的社区卫生服务中心每月上转患者<100例，75.00%（183/244）的社区卫生服务中心每月接收下转的患者数<10例。城区和郊区社区卫生服务中心每月上转患者数比较，差异有统计学意义（P<0.05）。结论　城市社区卫生中心与郊区卫生中心在双向转诊实行上存在诸多差异，且目前双向转诊仍以上转为主，建议通过完善郊区社区卫生服务建设、利用“互联网+”优势建立基于健康档案的双向转诊平台、积极组建区域医疗集团等措施建立健全双向转诊制度建设。

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