Page 98 - 中国全科医学2022-10

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1.School of Health Management，Harbin Medical University，Harbin 150081，China
2.School of Public Health Hangzhou Normal University，Hangzhou 311121，China
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Corresponding author：SUN Tao，Professor，Doctoral supervisor；E-mail：hydsuntao@126.com
【Abstract】 Background The narratives of hierarchical medical sytem are generally classified into two patterns，one is the
policy narrative，which is used to persuade the target audience to gain their support in practice，and the other is the academic narrative，
which describes the thinking process of researchers to explore problems and enhance perceptions using words. The narratives of the
hierarchical medical system are rich and diverse，but have been rarely systematically reviewed and summarized. Objective We explored
the evolution process，focuses and characteristics of academic narratives of 10-year development of hierarchical medical system in China
using social network analysis，aiming to provide a reference for improving the implementation of hierarchical medical system. Methods
On March 21，2021，we searched the database of CNKI for studies regarding hierarchical medical system in China published in academic
journals in Chinese during January 1，2009 to March 21，2021 using "hierarchical medical system" "seeking healthcare in an orderly
way" "seeking diagnosis and treatment services in an orderly way" "division of healthcare" "division of diagnosis and treatment" "first
contact in primary care" "treating acute and chronic diseases separately" "cooperation between tertiary and secondary/primary hospitals"
"bi-directional referrals" as keywords. Bibliometric methods，SATI 3.0 and UCINET 6.0 were used to explore the process，focuses and
characteristics of academic narratives of hierarchical medical system through time series analysis，high-frequency keywords analysis，
centrality analysis and small group analysis，and to generate visualized co-occurrence network diagrams of high-frequency keywords.
Results A total of 4 882 studies were included for analysis. According to the results of time series analysis，the development of the
hierarchical medical system could be roughly divided into three stages：embryonic stage（2009—2013），acceleration stage（2014—
2017）and standardization stage（2018 to present）. In terms of the use of frequency，the top five high-frequency keywords were
"hierarchical medical system" "medical consortium" "primary healthcare institutions" "bi-directional referrals" and "public hospitals". In
terms of closeness centrality，the top five high-frequency keywords were "hierarchical medical system" "medical consortium" "primary
healthcare institutions" "bi-directional referrals" and "general practitioners". Small-group analysis yielded three groups of word clusters：
core word clusters（including "medical consortium" "reform of public hospitals" "bi-directional referrals" "general practitioners" and "first
contact in primary care"），secondary word clusters（including "the internet" "internet-based healthcare" "internet-based hospital"
and "telemedicine"），and marginal word clusters（including "diabetes" "chronic disease" "cognition" and "influencing factors"）.
Health policy rhetoric was an important part of the core word clusters. And secondary and marginal word clusters were constantly evolving
and generating. Conclusion The academic narratives of hierarchical medical system have gradually derived from the mutually-promoted
development of policies and real implementation regarding the hierarchical medical system，generally demonstrated various structures and
relatively homogeneous research direction. Available academic and policy narratives of the hierarchical medical system are still limited to
the scope of guiding principles，and the implementation of the concept and system still relies on the top-down push from the policy-making
level，while the self-motivated micro-practices of hierarchical medical system in primary care have not yet emerged.
【Key words】 Hierarchical diagnosis；Academic narration；Social network analysis；Knowledge map；Research hotspots

实施分级诊疗制度是扭转医疗资源配置结构性失衡 也在不断生成与丰富 ［5］ ，已成为学界普遍关注的议题。
的关键举措，是重构我国卫生服务体系，提升服务效率 学术期刊作为分级诊疗学术叙事研究成果展示、交流和
的重要手段 ［1］ 。分级诊疗的叙事总体表现为两种模式， 传播的主要载体，其发展与繁荣推动了我国分级诊疗学
一种是在现实实践中被用于说服政策目标对象并获得其 术叙事理论体系和话语体系的建设。此外，学术期刊也
支持的政策叙事，另一种则是学术叙事，即透过语言来 为分级诊疗的现实实践提供了信息传递与反馈平台，其
记述研究者探索问题、增进认知（时）的思维活动过程， 所载信息可反作用于实践并指引未来分级诊疗现实实践
两种叙事模式旨在通过推动制度改革和体系重构，促进 的方向和进程。现阶段，分级诊疗学术叙事研究已经具
资源要素的解构、流动和重组，助力实现“构建合理有 有一定规模，内容丰富、题材多样，但较少有研究者对
序的就医新秩序”“激发服务体系活力”“重塑医疗生 该领域内的相关研究进行系统梳理和总结。本文在采用
态”“医疗服务需求与供给相匹配”等目标 ［2］ 。回顾“新 文献计量学方法进行一般文献计量分析的基础上，通过
医改”历程并总结经验，国家聚焦卫生体系与制度建设 运用信息可视化技术和工具对该领域的研究现状及热点
开展整体性改革，分级诊疗政策叙事成为健康服务递送 问题进行整体把握，以透视分级诊疗学术叙事话语全貌，
场域的集体共识。自此，产生了一组可共享的改革愿景。 阶段性梳理和总结分级诊疗学术叙事的结构与特征，避
在分级诊疗政策愿景的驱动之下，地方政府创新实践广 免未来分级诊疗学术研究场域内部信息熵的增加。通过
泛兴起与发展 ［3］ 。分级诊疗政策叙事引领改革走向， 对我国分级诊疗学术叙事的研究进程、热点及网络进行
其实践已“由点及面”在全国铺开 ［4］ 。分级诊疗学术 系统探析，希望能给分级诊疗学术叙事的规范演进提供
叙事滥觞于 2010 年，历经十余年的演化，其话语体系 些许参考。