社区首诊制研究

As the core element of classified medical care, the system of first contact care at community health institutions is essential for setting up a well structured and functional reasonable health service system, promoting rational use of health resources and controlling the unreasonable increasing of health cost. In this study, we mainly adopt the method of evidence-based health policy. The objective of this study is to explore the focus of first contact care system at community health institutions, the association between health service system, health reform and community health service development, and to analyze the effect and necessity, conditions and feasibility, obstacles and difficulties of the first contact care system at community health institutions. At the same time, by carrying out observational study in pilot population, we aim to explore the main elements of policy design such as the key point and process of implementing the first contact care system. At last, we plan to comprehensively survey the influence factors of first contact care system at community health institutions . The main innovations of this study include grasping the accurate opportunity for researching, more comprehensive and depth than previous studies, as well as more advanced research method. The prospective findings include defining the function and meaning, basic conditions and determinants, institutional elements, operation mode, referral processes and norms, interests of residents, responsibilities of health service providers and managements of the first contact care system at community health institutions. The achievements of this study may also be significant for national health and social security departments to determine whether or not to establish first contact care system at community achievements for all population or all people with health insurances.

社区首诊制是分级医疗制度的核心要素，对于建立层次分明、功能合理的卫生服务体系、合理使用卫生资源、控制卫生费用不合理增长，至关重要。本课题主要采用循证卫生政策学方法，明确社区首诊制与医改重心、卫生服务体系和社区卫生服务发展的关系，分析建立社区首诊制的作用与必要性、条件与可行性、障碍与困难；利用现有特殊人群社区首诊制试点进行现场观察研究，探索实行社区首诊制的关键环节、路径等政策设计要素；全面调查社区首诊制的影响因素。主要创新点在于：本选题把握住研究的良好时机，内容比同类研究全面、深入，研究方法先进。预期成果主要包括社区首诊制的作用和意义、基本条件与决定因素、制度要素、运作模式、转诊流程与规范、居民权益、服务机构和管理部门职责等，对国家卫生及社会保障等部门在是否建立全（医保）人群社区首诊制的决策方面具有重要价值。

社区首诊制的建立对分级诊疗制度的推进至关重要。国外“守门人”制度即强制性的社区首诊制政策，在控制医疗费用、合理利用卫生资源方面发挥了较大作用，且各利益方均能适应和接受该项制度。在我国，无论是政策制定者还是实施者，都比较了解其内涵，对社区首诊制的作用和意义比较认可，但对是否实行强制性的社区首诊政策依旧十分犹豫。本项目从政策研究和实证研究的角度探讨了强制性首诊政策实施的可行性及机制。结果表明社区首诊制的建立符合各利益相关集团的利益需求，已起到促进健康公平的作用；医患双方对社区首诊制均有较高的认可度和接受度，社区首诊制实施的可行性较好。研究结论对我国卫生政策的顶层设计具有重要的借鉴作用。..按照项目计划，课题组选择了深圳、南京、武汉三个城市对社区首诊制相关政策及实施效果进行了深入研究。明确了社区首诊制对调整病人流向、控制卫生费用的作用，探讨了社区首诊制可行性研究的必要性。结果表明，首诊人群与非首诊人群对社区首诊制的认知、意愿和满意度情况均具有差异。93.49%的就诊者（首诊者94.68%，非首诊者92.25%）生病时首选到社康中心就诊；首诊患者平均药品费用（32.28元）显著高于非首诊患者（24.04元）；73.47%的就诊者（首诊者74.16%，非首诊者69.71%）愿意接受社区首诊制；2.46%的首诊人群愿意接受医保卡绑定社康中心的制度。从医患双方的角度分析，分别有69.2%全科医生和62.5%综合医院医生认为社区卫生服务机构基本能够承担社区“守门人”职责；94.5%和85.7%的医生表示赞同实施社区首诊制；83.7%和81.5%的医生认为社区首诊制在引导居民就诊方面能够起到积极作用。认为社区卫生服务机构总体水平能够满足基本需求的患者比例分别为80.0%（南京）和71.8%（武汉）；分别有25.8%和33.4%的患者表示不愿接受该制度。..研究表明，在社区首诊制实施过程中，应充分发挥政府主导作用，完善医保制度；加强信息系统整合，不断提升社区卫生服务水平和医生服务意识，提高患者就诊满意度；同时，应加强居民对制度内涵的理解，促进社区首诊制的推广。