Effect of contracting contracts of "1+1+1" medical institutions based on propensity score
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摘要:
目的 对上海市黄浦区某社区“1+1+1”医疗机构组合签约效果进行评价，为下一步工作指明优化方向。 方法 于2019年6月—2019年10月，根据签约时长和就诊次数，分层随机抽取上海市黄浦区某社区签约组和未签约组居民各603例，并分别于2019年11月、2020年6月按年份采集2018、2019年间研究对象的就诊行为和药品费用信息。 结果 共获得签约和未签约居民各602例数据。2组居民对社区卫生服务中心的信任程度、首诊意愿、便利性、服务态度、服务效果、家庭医生费用管理的看法等方面差异均有统计学意义(均P＜0.05)，且签约组居民表达信任、愿意、满意、希望及早落实等积极态度的比例更高。倾向性评分匹配前后，2组居民在2018、2019年本社区就诊次数、2年次数差额和药品总费用支出等方面差异均有统计学意义(均P＜0.05)，在2018、2019年药品总费用差额以及自付费用等方面比较，差异无统计学意义(均P＞0.05)，2018、2019年自付费用间差额，在匹配前差异均有统计学意义，匹配后则差异无统计学意义。 结论 签约服务较好满足了社区中对社区卫生中心主观评价高、配药需求高的居民的需求，并对其下沉社区就诊有促进作用，但并未形成口碑传播效应和带动效应；家庭医生尚未借助签约发挥控费作用，签约尚处在促进家庭医生与居民建立管理服务的关系阶段。 -
关键词:
- “1+1+1”医疗机构组合签约 /
- 效果 /
- 就诊 /
- 费用
Abstract:Objective To evaluate the effect of the "1+1+1" medical institution combination contract in a community in Huangpu District, Shanghai, and point out for the next step of optimisation direction. Methods From June 2019 to October 2019, based on the length of contract signing and the number of visits, 603 cases of residents in a community in Huangpu District, Shanghai, were hierarchically and randomly selected, and the medical visits and cost information of the study subjects between 2018 and 2019 were collected in November 2019 and June 2020, respectively. Results A total of 602 cases of contracted and non-contracted residents were obtained. Significant differences in the degree of trust in the community health service centre, willingness for first consultation, convenience, service attitude, service effect and views on family doctor cost management were observed between the two groups (all P < 0.05), and the residents in the contract group highly expressed trust, willingness, satisfaction, hope for early implementation and other positive attitudes. Before and after propensity score matching, the two groups of residents had significant differences in the number of community visits, the difference between the number in two years, and the total drug expenditure in 2018 and 2019 (all P < 0.05). No significant difference in the total cost difference and out-of-pocket expenses in 2018 and 2019 was observed (all P > 0.05). This difference between out-of-pocket expenses in 2018 and 2019 was significantly different before matching but not after matching. Conclusion The contracted service satisfies the needs of residents in the community who have high subjective evaluations of community health centres and high drug dispensing needs and promotes their community visits, but it has not formed a word-of-mouth transmission effect and a driving effect. Furthermore, family doctors have not yet used the contract service to control the cost, and the contract service is still in the stage of promoting the establishment of management service relationships between family doctors and residents. -
表 1 2组居民基本情况比较
Table 1. Comparison of basic conditions between the two groups of residents
项目 类别 未签约组(n=602) 签约组(n=602) 统计量 P值 性别[例(%)] 女性 312(51.8) 322(53.5) 0.333a 0.564 男性 290(48.2) 280(46.5) 年龄[M(P25, P75)，岁] 64(56, 71) 67(60, 76) 5.267b ＜0.001 民族[例(%)] 汉族 601(99.8) 602(100.0) 1.001a 0.317 蒙古族 1(0.2) 0 职业[例(%)] 公务员 0 5(0.8) 245.326a ＜0.001 事业单位人员 83(13.8) 96(15.9) 国有企业 132(21.9) 347(57.6) 民营企业 117(19.4) 56(9.3) 个体户 16(2.7) 4(0.7) 务农 2(0.3) 0 工人 221(36.7) 53(8.8) 学生 5(0.8) 0 自由就业 21(3.5) 29(4.8) 其他 5(0.8) 12(2.0) 是否离退休[例(%)] 否 163(27.1) 113(18.8) 11.752a 0.001 是 439(72.9) 489(81.2) 文化程度[例(%)] 未上过学 7(1.2) 12(2.0) 20.003a ＜0.001 小学 49(8.1) 62(10.3) 初中 164(27.2) 209(34.7) 高中 224(37.2) 216(35.9) 其他 158(26.2) 103(17.1) 婚姻情况[例(%)] 未婚 40(6.6) 10(1.7) 20.622a ＜0.001 已婚 527(87.5) 562(93.4) 离异 2(0.3) 4(0.7) 丧偶 33(5.5) 26(4.3) 每月可支配收入[例(%)] ＜500元 5(0.8) 1(0.2) 10.732a 0.057 500~＜1 000元 6(1.0) 8(1.3) 1 000~＜2 000元 38(6.3) 28(4.7) 2 000~＜3 000元 80(13.3) 102(16.9) 3 000~＜5 000元 304(50.5) 270(44.9) ≥5 000元 169(28.1) 193(32.1) 医保形式[例(%)] 城镇医疗保险 600(99.7) 601(99.8) 1.001a 0.606 新型农村合作医疗保险 1(0.2) 1(0.2) 自费 1(0.2) 0 有无商业保险[例(%)] 无 600(99.7) 602(100.0) 2.003a 0.157 有 2(0.3) 0 注：a为χ2值，b为Z值。 
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表 2 2组居民健康状况及就医情况比较[例(%)]
Table 2. Comparison of health status and medical treatment of residents in the two groups [cases (%)]
项目 类别 未签约组(n=602) 签约组(n=602) χ2值 P值 项目 类别 未签约组(n=602) 签约组(n=602) χ2值 P值 高血压 无 380(63.1) 354(58.8) 2.359 0.125 消化道疾病 无 586(97.3) 579(96.2) 1.298 0.254 有 222(36.9) 248(41.2) 有 16(2.7) 23(3.8) 高血脂 无 531(88.2) 497(82.6) 7.693 0.006 其他疾病 无 593(98.5) 568(94.4) 15.073 ＜0.001 有 71(11.8) 105(17.4) 有 9(1.5) 34(5.6) 糖尿病 无 533(88.5) 512(85.0) 3.196 0.074 需要长期用药 无 361(60.0) 202(33.6) 84.344 ＜0.001 有 69(11.5) 90(15.0) 有 241(40.0) 400(66.4) 脑卒中 无 574(95.3) 550(91.4) 7.712 0.005 配药需求 无 259(43.0) 137(22.8) 56.007 ＜0.001 有 28(4.7) 52(8.6) 有 343(57.0) 465(77.2) 心脏疾病 无 551(91.5) 527(87.5) 5.106 0.024 基本诊疗需求 无 254(42.2) 229(38.0) 2.161 0.142 有 51(8.5) 75(12.5) 有 348(57.8) 373(62.0) 肾脏疾病 无 598(99.3) 587(97.5) 6.471 0.011 康复护理需求 无 591(98.2) 579(96.2) 4.358 0.037 有 4(0.7) 15(2.5) 有 11(1.8) 23(3.8) 骨质疏松 无 596(99.0) 567(94.2) 21.235 ＜0.001 其他需求 无 598(99.3) 602(100.0) 4.013 0.045 有 6(1.0) 35(5.8) 有 4(0.7) 0
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表 3 2组居民对社区卫生服务中心评价比较[例(%)]
Table 3. Comparison of two groups of residents' evaluation on community health service centers [case (%)]
项目 类别 未签约组(n=602) 签约组(n=602) 统计量 P值 社区卫生服务中心的信任程度 很不信任 4(0.7) 1(0.2) -18.745a ＜0.001 不太信任 128(21.3) 7(1.2) 比较信任 445(73.9) 308(51.2) 非常信任 25(4.2) 286(47.5) 是否愿意到中心接受首诊 否 452(75.1) 44(7.3) 570.732b ＜0.001 是 150(24.9) 558(92.7) 来中心就医的便利性是否满意 满意 197(32.7) 527(87.5) -19.444a ＜0.001 一般 392(65.1) 75(12.5) 不满意 13(2.2) 0 对中心医务人员的服务态度是否满意 满意 257(42.7) 549(91.2) -17.883a ＜0.001 一般 344(57.1) 53(8.8) 不满意 1(0.2) 0 对中心医务人员的服务效果是否满意 满意 240(39.9) 543(90.2) -18.281a ＜0.001 一般 361(59.9) 59(9.8) 不满意 1(0.2) 0 对今后开展家庭医生费用管理的看法 希望及早落实 94(15.6) 375(62.3) 284.771b ＜0.001 不希望由家庭医生管理 58(9.6) 9(1.5) 无所谓 450(74.8) 218(36.2) 注：a为Z值，b为χ2值。
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表 4 签约居民与未签约居民社区就诊次数比较[M(P25, P75)]
Table 4. Comparison of the number of community visits between contracted and non-contracted residents[M(P25, P75)]
项目 样本 例数 签约组 未签约组 Z值 P值 2018年就诊次数 匹配前 1 204 8.0(3.0, 19.0) 1.0(1.0, 3.0) -16.320 ＜0.001 匹配后 234 13.0(3.0, 25.0) 2.0(1.0, 6.0) -7.239 ＜0.001 2019年就诊次数 匹配前 1 204 31.0(6.0, 76.0) 0.0(0.0, 3.0) -20.477 ＜0.001 匹配后 234 40.0(7.5, 84.5) 1.0(0.0, 5.0) -8.723 ＜0.001 2018与2019年就诊次数差额 匹配前 1 204 31.0(6.0, 76.0) 0.0(0.0, 3.0) -20.477 ＜0.001 匹配后 234 40.0(7.5, 84.5) 1.0(0.0, 5.0) -8.723 ＜0.001
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表 5 签约居民与未签约居民药品总费用、自付费用比较[M(P25, P75)]
Table 5. Comparison of total drug costs and out-of-pocket costs between contracted and non-contracted residents[M(P25, P75)]
项目 变量 样本 例数 签约组 未签约组 Z值 P值 2018年 药品总费用 匹配前 1 204 1 291.2(327.4, 3 950.3) 155.9(26.8, 523.2) -15.844 ＜0.001 匹配后 234 2 147.8(429.6, 5 300.8) 220.7(40.5, 899.1) -6.927 ＜0.001 药品自付费用 匹配前 1 204 0.0(0.0, 0.0) 0.0(0.0, 0.0) -1.415 0.157 匹配后 234 0.0(0.0, 0.0) 0.0(0.0, 0.0) ＜0.001 0.999 2019年 药品总费用 匹配前 1 204 2 814.1(611.9, 8 081.4) 664.8(0.0, 3 445.9) -9.293 ＜0.001 匹配后 234 4 580.0(649.2, 9 155.9) 970.4(104.6, 5 163.6) -3.246 0.001 药品自付费用 匹配前 1 204 0.0(0.0, 0.0) 0.0(0.0, 0.0) -1.912 0.056 匹配后 234 0.0(0.0, 0.0) 0.0(0.0, 0.0) -0.006 0.995 2018与2019年药品总费用、自付费用差额 药品总费用 匹配前 1 204 759.3(-137.2, 3 856.7) 325.2(-16.6, 2 450.7) -0.507 0.612 匹配后 234 1 477.9(-127.3, 4 942.8) 603.4(0.0, 4 386.2) -0.184 0.854 药品自付费用 匹配前 1 204 0.0(0.0, 0.0) 0.0(0.0, 0.0) -2.319 0.020 匹配后 234 0.0(0.0, 0.0) 0.0(0.0, 0.0) -0.006 0.995
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