人际连续性视域下慢性病健康管理研究：效果评估与制度优化

Nowadays, it is not easy for China to dealt with chronic diseases and aging problems because of the segmentation of healthcare delivery system and the disorder of healthcare utilization. Though WHO advocated to improve healthcare delivery and the effects of health management by ameliorating interpersonal continuity which means one patient went to see the same healthcare provider (including consulting health problems, receiving treatment and rehabilitation, etc.) and then to build a stable and long-term relationship with mutual trust between each other, it is controversial that whether interpersonal continuity has some positive effects on health management. There is the lack of convincing evidence to answer these questions: can the health management effect be improved by ameliorating interpersonal continuity? How about the degree of improvement? Can the effects be totally improved or partially improved? Therefore, this research is designed to answer the questions above and the research approaches are as follows: firstly, to build index system for interpersonal continuity and using it to evaluate interpersonal continuity conditions for chronic disease patients. Secondly, according to the interpersonal continuity score, split all the patients into 3 groups and after matching the patients by propensity score to explore the short-term and long-term effects of interpersonal continuity on health management. And the long-term effects are evaluated by Markov model. Thirdly, to bring up some suggestions for chronic disease management.

现阶段，我国割裂的医疗与公共卫生服务提供方式以及无序的卫生服务利用方式，已难以妥善应对慢性病和老龄化带来的危害。WHO提倡通过提高人际连续性（指的是患者因某种疾病长期就诊（包括健康咨询、诊疗、康复等）于同一个卫生服务提供者，医患间建立起信任、稳定和长期的关系）来改善服务提供和居民健康水平，但人际连续性对健康管理的效果尚存争议。“提高人际连续性能否改善健康管理效果？改善的力度有多大？人际连续性具有总体改善健康管理效果的功用，抑或只能部分改善？”对上述问题的回答尚且缺乏令人信服的证据。因此，拟通过以下研究解答上述问题：首先，构建人际连续性评价指标体系，探索慢性病患者人际连续性状况。其次，根据人际连续性得分高低，将慢性病患者分成3组，通过PSM配对控制混杂因素后，比较不同人际连续性对健康管理的短期效果和长期效果（长期效果通过Markov模型来实现）。最后，提出慢性病健康管理的相关政策建议。

本研究梳理了人际连续性评价指标，分析出高血压人际连续性评价指标的热点趋势和发展前沿，并构建了评价指标体系，评估了我国慢性病患者人际连续性现状。其次，测量了人际连续性对慢性病患者健康管理效果的影响。再次，提出了人际连续性视域下慢性病健康管理优化的建议。.主要发现与结论：①评价高血压患者人际连续性的“热点”指标主要有UPC、COC，MMCI，SECON等，“热点”指标随着时间的变化有所变化。COC逐渐取代UPC，占据评价指标网络的核心地位。②综合考虑就诊的集中程度、分散程度、顺序性，可选取UPC、COC、SECON这3个指标评价人际连续性。③高血压患者人际连续性测量结果并不理想。其中，UPC均值为0.636，COC均值为0.439，SECON均值为0.464。此外，人际连续性好与不好的人群除了在年龄方面没有统计学差异，在性别构成、医疗费用、门诊就诊总次数和因高血压门诊就诊次数方面均具有显著的统计学差异。④人际连续性对高血压健康管理具有一定的积极影响。宜昌二手数据分析结果显示，人际连续性好有利于降低高血压门诊花费，但并不能认为人际连续性好能够降低患者的住院情况的发生。黔江队列研究结果显示，人际连续性好有利于改善高血压患者的生命质量。.人际连续性视域下改善慢性病患者健康管理效果的建议如下：①打破信息孤岛效应，畅通信息流。在卫生系统内部建立起慢性病患者全生命周期的健康数据库；在确保信息安全的前提下，打通职能部门间的信息共享渠道，促进人口信息、经济信息、社会信息、医疗信息等的多维度融合。②完善家庭医生功能，逐步形成慢性病患者健康守门人角色，促进家庭医生与慢性病患者之间“负责-信任”关系的建立。③构建“集门诊和住院为一体，集医疗与预防为一体”的综合型按人头支付方式，完善家庭医生激励机制。