Research on the construction of effectiveness evaluation index system for family doctor contract service model
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摘要:
目的 目前我国各地区均已形成符合当地特色的家庭医生签约服务模式，但尚缺乏科学、可行的效果评价工具。为此，本研究构建我国家庭医生签约服务模式效果评价指标体系，旨在进一步推动家庭医生签约服务优质、高效发展。 方法 通过文献回顾分析并经小组讨论形成初步效果评价指标体系及专家咨询表。于2021年9月—2021年12月，采用德尔菲法，以Better Together模型为理论基础，“结果框架”为指导，经过两轮专家咨询，确定最终家庭医生签约服务模式效果评价指标体系，并通过专家咨询和层次分析法，确立各指标权重。 结果 专家积极性和权威程度较高, 两轮专家咨询表的有效回收率分别为100%和75%，权威程度系数分别为0.898和0.877；专家意见趋于一致, 两轮肯德尔系数分别为0.245(χ2=393.205，P < 0.001)和0.252(χ2=453.417，P < 0.001)。通过两轮专家咨询，最终构建以人群健康、服务质量、服务效率、成本控制、居民认可、亲密度为主要内容的家庭医生签约服务模式效果评价指标体系，其具体有5个一级指标、15个二级指标、48个三级指标，权重系数分别为0.217、0.217、0.196、0.181、0.188。 结论 本研究专家积极性、权威性、协调程度均较高，最终构建出的家庭医生签约服务模式效果评价指标体系结果可靠，从而为国内各地区家庭医生签约服务模式提供科学、客观的效果评价工具。 -
关键词:
- 家庭医生签约服务模式 /
- 效果 /
- 德尔菲法 /
- 层次分析法 /
- 指标体系
Abstract:Objective Currently, various regions in China have developed family doctor contract service models fitting local characteristics, however, it still lacks scientific and feasible tools for evaluating the effectiveness. Therefore, this study aims to develop the effectiveness evaluation index system for family doctor contract service models, which would promote the high-quality development of family doctor services. Methods The preliminary evaluation index system and expert consultation table were formed through literature reviews and group discussions. From September 2021 to December 2021, taking the Better Together model as the theoretical basis and the "results framework" as the guidance, the final effectiveness evaluation index system for family doctor contract service models was determined through two rounds of expert consultations using the Delphi method. The weights of each index were determined through expert consultations and analytic hierarchy process. Results The response rates of experts in the two rounds of consultation were 100% and 75% respectively, which indicated the experts were highly motivated. The authority coefficients for the two rounds of consultation were 0.898 and 0.877 respectively; The Kendall coefficients were 0.245 (χ2=393.205, P < 0.001) and 0.252 (χ2=453.417, P < 0.001) respectively, which indicated experts ' opinions tended to be consistent. Through two rounds of expert consultation, the final effectiveness evaluation index system for family doctor contract service models was constructed, mainly focusing on population health, service quality, service efficiency, cost control, resident recognition, and intimacy. The system consisted of 5 first level indicators, 15 second level indicators, and 48 third level indicators, with weight coefficients of 0.217, 0.217, 0.196, 0.181, and 0.188, respectively. Conclusion The experts in this study are highly motivated, authoritative and coordinated, and the final effectiveness evaluation index system for family doctor contract service models are reliable, which can provide an objective and scientific tool of evaluating the effectiveness for the family doctor contract service models. -
表 1 家庭医生签约服务模式效果评价理论框架
Table 1. Theoretical framework for evaluating the effectiveness of the Contracted family doctor service model
评价维度 内涵 人群健康 家庭医生签约服务所实现地区的人群健康产出，如居民健康状况等。 服务质量 家庭医生为社区居民提供包括技术和服务质量在内的医疗卫生和健康管理服务。 服务效率 家庭医生签约服务的覆盖及规范程度情况，包括居民签约覆盖有效签约、有效就诊及转诊情况等。 成本控制 居民在家庭医生签约服务下的就医成本及费用控制程度。 居民认可及满意度 家庭医生签约服务下，居民的认可、满意程度。 
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表 2 专家权威程度的量化情况
Table 2. Quantized values of the bases for experts to assess the values of the questions
判断依据 对专家判断的影响度 大 中 小 理论分析 0.30 0.20 0.10 实践经验 0.50 0.40 0.30 国内外同行的了解 0.10 0.10 0.05 主观判断 0.10 0.10 0.05
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表 3 专家的基本情况
Table 3. Sociodemographic data of the experts involved in the consultation
特征 类别 人数 百分比(%) 性别 男性 14 58.3 女性 10 41.7 职称 中级 10 41.7 副高级 4 16.7 高级 10 41.7 学历 本科 14 58.3 硕士 6 25.0 博士 4 16.7 专业 全科医学 10 41.7 公共卫生 2 8.2 临床医学 10 41.7 社区卫生保健 1 4.2 卫生事业管理 1 4.2
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表 4 专家意见协调程度
Table 4. The Kendall's W results of the first and second rounds of Delphi expert consultation
指标 第一轮咨询 第二轮咨询 Kendall’s W χ2值 P值 Kendall’s W χ2值 P值 一级指标 0.534 51.294 ＜0.001 0.534 51.294 ＜0.001 二级指标 0.241 80.850 ＜0.001 0.229 82.557 ＜0.001 三级指标 0.217 245.072 ＜0.001 0.229 296.448 ＜0.001 全部 0.245 393.205 ＜0.001 0.252 453.417 ＜0.001
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表 5 家庭医生签约服务模式效果评价指标体系
Table 5. Weights of the dimensions, indices and subindices of the contracted family doctor service model
指标(权重) 重要性评分(x±s) 组合权重 指标(权重) 重要性评分(x±s) 组合权重 A人群健康(0.217) 5.00±0.00 C服务效率(0.196) 4.50±0.55 A1签约居民就诊 4.67±0.52 0.071 C1签约覆盖率 3.83±0.75 0.043 A1-1签约居民年人均门诊就诊频次 4.17±0.75 0.024 C1-1常住人口签约覆盖率 4.50±0.84 0.022 A1-2签约居民因高血压相关疾病住院比例 4.17±0.75 0.024 C1-2重点人群签约覆盖率 4.50±0.84 0.022 A1-3签约居民因糖尿病相关疾病住院比例 4.17±0.75 0.024 C2签约重点人群有效管理率 4.67±0.52 0.053 A2重点疾病控制 5.00±0.00 0.076 C2-1签约居民孕产妇早孕建册率与产后访视率 4.67±0.52 0.019 A2-1签约居民高血压规范管理率 4.67±0.52 0.015 C2-2签约居民肺结核病患者管理率与规则服药率 4.17±0.98 0.017 A2-2签约居民血压控制率 4.83±0.41 0.015 C2-3签约居民严重精神障碍患者规范管理率 4.17±0.98 0.017 A2-3签约居民糖尿病规范管理率 4.83±0.41 0.015 C3有效就诊率 4.67±0.52 0.053 A2-4签约居民血糖控制率 4.83±0.41 0.015 C3-1签约社区就诊率 4.83±0.41 0.012 A2-5签约居民高血压、糖尿病并发症发病率 4.67±0.52 0.015 C3-2签约社区就诊率与上年同期变化 4.33±0.52 0.011 A3居民健康素养水平 4.67±0.52 0.071 C3-3签约医疗机构组合就诊率 4.17±0.75 0.010 A3-1签约居民健康问题知晓率 4.00±0.89 0.036 C3-4签约医疗机构组合就诊率与上年同期变化 4.00±0.89 0.010 A3-2签约居民健康素养水平 4.00±1.09 0.036 C3-5延伸处方实施情况 4.17±0.75 0.010 B服务质量(0.217) 5.00±0.00 C4有效双向转诊 4.17±0.75 0.047 B1签约居民电子健康档案质量 4.50±0.55 0.055 C4-1社区上转至上级医院人次数与上年同期变化 4.33±0.82 0.023 B1-1电子健康档案规范建档率 4.33±1.03 0.013 C4-2上级医院下转人次数与上年同期变化 4.50±0.55 0.024 B1-2电子健康档案利用率 4.50±0.55 0.014 D成本控制(0.181) 4.17±0.75 B1-3签约居民电子健康档案更新率 4.83±0.41 0.015 D1人均医疗成本 4.17±0.98 0.091 B1-4签约居民电子健康档案采集率 4.50±0.84 0.014 D1-1签约居民人均医保费用 4.33±0.82 0.030 B2信息系统建设质量 4.50±0.84 0.055 D1-2签约社区发生费用占比 4.33±0.82 0.030 B2-1设置签约服务管理系统 4.00±0.89 0.014 D1-3签约组合内发生费用占比 4.33±0.82 0.030 B2-2设置签约居民健康评估系统 4.00±0.63 0.014 D2家庭医生有效控费占比 4.17±0.98 0.091 B2-3区域内医疗机构间健康档案、公共卫生、检查检验等信息互联互通 4.20±0.49 0.014 D2-1家庭医生合理控制签约居民医保费用 4.33±0.82 0.031 B2-4设置住院病史信息调阅系统 3.83±0.98 0.013 D2-2家庭医生合理控制签约居民门诊就诊频次 4.00±1.26 0.029 B3人才培养质量 4.33±0.82 0.053 D2-3有效控费发现及上报 4.33±0.82 0.031 B3-1促进家庭医生学习及培训 4.67±0.82 0.014 E居民认可及亲密度(0.188) 4.33±0.52 B3-2落实上级医院医生来社区开设教学门诊 4.42±0.49 0.013 E1居民对签约医生知晓及认可 4.50±0.84 0.096 B3-3专家下社区开展教学查房、疑难病例讨论、专题讨论 4.33±0.52 0.013 E1-1签约居民对家庭医生的知晓率 4.67±0.52 0.033 B3-4开展全专结合诊疗情况(加分指标) 4.67±0.82 0.013 E1-2签约居民预约就诊率 4.50±0.55 0.032 B4医疗事故及投诉 4.50±0.55 0.055 E1-3签约居民预约门诊履约率 4.50±0.84 0.032 B4-1签约居民医疗事故发生 4.67±0.52 0.030 E2满意度 4.50±0.55 0.092 B4-2家庭病床管理建床及不合规发生 4.00±0.89 0.025 E2-1签约服务满意度 4.50±0.84 0.033 E2-2家庭医生满意度 4.12±0.75 0.031 E2-3家庭病床服务满意度 3.83±0.75 0.028
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