基于临床路径的慢性病分级诊疗模式评价与优化研究：以糖尿病为例

At present, the disorder situation of medical services has become the biggest problem for other problems having been greatly alleviated after the health care system reform since 2009. Practice at home and abroad has proved that referral management system of medical care is an effective way to solve this problem, and clinical pathway is the key to this system. In view of the fact，the hierarchical medical model based on clinical pathway, taking diabetes diseases as pilot, was proposed in Jiangxi province to solve the problem. Due to the lack of systematic and quantitative performance appraisal of this policy, evaluation system would be constructed based on literature analysis, Delphi method and AHP method, to evaluate the realization of policy objects and the gap between the achievement and the explanation of the policy，and analyze the contribution of each support policy. And in view of the fact that no systematic and quantitative interpretation model was constructed to explain the difficulties in achieving the goals of this policy, great efforts would be made to collect all the influencing factors and their indicators, construct a theoretical model to explain the gap based on the macro model of health system, quantitatively verify and perfect the interpretation model using structural equation model(SEM) based on empirical data from the pilot units in Jiangxi province, and identify key factors through the SEM model. Finally，some optimization strategies and measures would be developed on the basis of the game model of key interest groups involved in key factors. After intervention and evaluation of these measures, the final optimization strategies would be provided. And all these studies would have great value to perfect the hierarchical medical system in China.

大病小病都涌向大医院的无序就医状况，已成为新医改后面临的最大问题；而分级诊疗是解决无序就医的有效途径，临床路径管理是分级诊疗成功的基础与保障。为此，融合多元政策，江西省提出了基于临床路径的分级诊疗模式，并以糖尿病为突破口展开试点。但是，当前尚无对该模式实施效果的评价研究，缺乏对影响该模式目标实现的因素及其作用的系统、定量分析。因此，本研究以优化分级诊疗制度为目的，使用文献分析、特尔斐法、层次分析法等方法构建效果评价指标体系，综合评估分级诊疗目标的实现度、与期望差距及支撑政策贡献度；系统搜集各种影响因素及其表达指标，依据卫生系统宏观模型构建差距解释的理论模型，定性明确各因素的交互关系及其作用机制；利用实证数据构建结构方程模型，定量修正解释模型，确定关键因素；根据其中的关键利益集团博弈模型，研制具有针对性的优化策略，通过干预试点、评价与优化，构建最终优化策略，为分级诊疗制度的完善提供依据。

上下衔接的临床路径是实现分级诊疗目标的重要技术条件，为此江西省开展临床路径分级诊疗模式试点。为评价该模式成效，采用文献分析法、德尔菲法等方法，构建基层医疗卫生机构基本诊疗路径实施效果评价指标体系（包括3个一级指标、16个二级指标）、慢性病分级诊疗模式成效评估指标（包括4个一级指标、9个二级指标）。实证评价结果显示：基本诊疗路径明显缩短基层医疗卫生机构治疗时间、降低治疗费用；江西省基本完成2017年慢性病分级诊疗政策目标，但效果出现明显波动，反映出合理有效的就医秩序尚未完全形成，存在基层服务资源短缺与能力不足、上下级医疗机构资源和利益共享机制不规范、居民基层诊疗意愿低、医保引导力度不足、支撑政策不到位等持续长期存在的32个问题。结合文献、咨询和现场调查结果，提出了人口需要、宏观环境、卫生资源配置、政策实施等4类13种影响因素，构建了慢性病分级诊疗模式的理论模型，并筛选形成了39个表达指标。相关影响因素的实证分析显示基层服务能力不足、二三级医院生存压力大、相关群体制度与利益认识偏差是导致慢性病分级诊疗政策无法有效实施的主要因素，而利益冲突是其本质原因。利益相关者分析发现，分级诊疗的关键利益相关者为医患双方，而两个群体不仅利益诉求存在差异，双方对自己及对方利益诉求的认识也存在差异，成为利益冲突的重要成因。为此，课题组提出改善医患双方对分级诊疗及对各方利益影响的认识、以人事制度改革为核心提升基层医疗卫生服务能力、以医院职能划分为基础的二三级医院投入模式改革三大优化策略。