分级诊疗与慢性病优化管理实证研究

摘要

目的：以社区慢性病优化管理为突破口，探讨实现和完善分级诊疗体系的有效模式。方法：通过评价项目在实施分级诊疗工作前后入组患者临床指标管理效果、区域医疗协作情况、患者满意度以及相关卫生经济成本，分析模式的效果。结果：上海嘉定分级诊疗模式实施12个月后，患者临床管理效果提升明显，全-专联合背景下的转诊会诊数量及内涵均有明显提升；卫生经济学分析，分级诊疗一年节省疾病支出显著。结论：政府主导、专科参与、社区联合的上海嘉定分级诊疗模式，以慢性病优化管理为切入点，以疾病管理质量为工作要素，在完善社区卫生服务绩效激励机制的基础上，有效推动了区域医疗机构合作和分级诊疗工作的开展，实现了区域内医疗资源的高效利用和有序就医。%Objectives:To explore the effective mode in hierarchical diagnosis and treatment with the breakthrough of improving chronic diseases control at community. Methods: To evaluate the effects of the model of hierarchical diagnosis and treatment, the difference of clinical results, care cooperation pathway, patient satisfaction and the cost of care before and after the new model were compared. Results: After 12 months, the clinical management effects of the patients were significantly improved. Under the cooperation between specialist and general practitioner, the number of referral and consultation was also increased obviously. In health economy analysis, the cost of disease was significantly saved in hierarchical diagnosis. Conclusions: The hierarchical diagnosis of Shanghai Jiading model, which was promoted by government, cooperated between hospital and general community health facilities would improve the efficiency of health care system.