| Objective : Since the implementation of the new medical reform,the construction of medical association has achieved certain successful experiences,however,its effective implementation and optimal operation are still in the exploration stage.In this study,Nanning Hospital X was selected as a case study to analyze the operational effects of its tightly-knit medical association construction,with the aim of providing reference and reference for promoting and improving the construction of tightly-knit medical associations in Guangxi and other minority areas.Methods: This study used the methods of literature research,case analysis,qualitative interview,comparative analysis and descriptive statistics to analyze and summarize the service mode of hierarchical diagnosis and treatment and the operation practice of the hierarchical diagnosis and treatment system of X hospital in Nanning.(1)Using literature research method,the study compare the policies,basic theories and classical models related to the hierarchical diagnosis and treatment system,analyzes the current situation of the operation of the hierarchical diagnosis and treatment system and summarizes the effects of the hierarchical diagnosis and treatment system.(2)Using the case study method,Nanning Hospital X was selected as a case study based on the theoretical sampling principle to analyze the operation status and effect of the close medical association model in Hospital X.(3)Using qualitative interview method,interviews were conducted with stakeholders,including managers,inpatients and government officials of hospital x,to understand the current situation and effects of the implementation of the hierarchical diagnosis and treatment system in hospital x.(4)Using the comparative analysis method,the dynamic changes in the operational efficiency of hospital x and the four primary hospitals supported by the hospital were compared and analyzed after the implementation of the hierarchical diagnosis and treatment system.(5)Using the descriptive statistics method,we analyzed the operation of hospital X and its supported primary hospitals after the implementation of the hierarchical diagnosis and treatment system by using the chain rate and growth rate indicators.Results:(1)The results of literature research shown that: the hierarchical diagnosis and treatment system had a relatively rich theoretical foundation,which has been covered by domestic and foreign research,and different models and types of exploration have emerged;currently,the trend of positive guidance for the hierarchical diagnosis and treatment system at the policy level is obvious,but how to optimize the implementation path still needs further consideration.(2)The results of case analysis shown that the practice of the hierarchical diagnosis and treatment system in hospital X is gradually implemented in accordance with the national policy and Guangxi policy guidelines in combination with the conditions in the western region,and the implementation has realistic necessity and rationality.(3)The results of qualitative interviews show that there is a siphoning effect on medical and health resources in X hospital and other upward transfer hospitals after the implementation of the hierarchical diagnosis and treatment policy;in the actual operation,the number of upward transfers far exceeds the number of downward transfers,the hierarchical diagnosis and treatment pattern is not really formed,and the upward and downward linkage mechanism needs to be further improved;a long-term mechanism of resource sharing in terms of manpower,instruments and equipment,and medical technology should be formed.(4)The results of descriptive statistics shown that.First of all,the operation of hospital x after the implementation of the tightly-knit medical association is as follows.In terms of the number of beds: from 1,780 in 2015 to 2,137 in 2020,with a CAGR of 17.6%.In terms of health human resources: the total number of employees increased from 3,893 to 4,868,with an average annual growth rate of 4.57%.The number of health technicians increased from 2,766 in 2015 to 3,783 in2020,with an average annual growth rate of 6.46%.The total number of doctors increased from 890 in 2015 to 1205 in 2020,with an average annual growth rate of 6.25%.The total number of nurses increased from 1,359 to 2,024 in 2020,with an average annual growth rate of 8.92%.In terms of total medical services: annual outpatient and emergency visits increased from 2,348,100 in 2015 to 2,604,816 in 2019,with an average annual growth rate of 2.63%.The annual number of hospital discharges increased from69,309 in 2015 to 79,326 in 2019,with an average annual growth rate of 3.43%.The annual number of inpatient surgeries rose from 56,286 in 2015 to 86,714 in2019,with an average annual growth rate of 11.4%.In terms of medical service efficiency: the average hospitalization day decreased from 9.44 days in 2015 to 8.4 days in 2020,which is lower than the average hospitalization day of 10.1 days and 9.5 days in tertiary hospitals nationwide in the same period.The bed utilization rate increased from 101.03%in 2015 to 101.64% in 2019.In terms of economic performance: from 2015 to 2020,the average cost of an outpatient emergency visit at hospital x increased from 318 yuan in 2015 to430 yuan in 2020,with an average annual growth rate of 4.44%.The average cost of inpatient hospitalization grows from $16,970 in 2015 to $19,750 in 2020 with an average annual growth rate of 3.08%.Emergency outpatient revenue grew from $768,492,000 in 2015 to $104,074,000 in 2019,an average annual growth rate of 7.88%;total inpatient revenue rose from $127,362,000 in 2015 to$163,133,000 in 2019,an average annual growth rate of 6.38%.In terms of medication use: x hospital drug ratio from 2015-2020 decreased from 38.08% in 2015 to 28.08% in 2020,DDD value was basically at 40.0,base drug ratio rose from 13.35% in 2015 to 32.83% in 2020,antibiotic utilization rate decreased from 15.44% in 2015 to 7.08% in 2020.Secondly,the operation of the four primary hospitals supported by hospital x after the implementation of the close medical association is as follows.In terms of the number of beds: the Third People’s Hospital of Hechi City reached 696 in 2020 from 640 in 2015,with a 2.35 % ringgit growth rate.Du’an County People’s Hospital from 585 in 2015 to 650 in 2019,with a Yo Y growth rate of 3.17 %.Dahua County People’s Hospital from 540 in 2015 to 697 in2020,with a 27.42 % Yo Y growth rate.Fusui County People’s Hospital from630 in 2015,reducing to 560 in 2020.In terms of human resources for health: the total number of employees of the Third People’s Hospital of Hechi City increased from 972 in 2015 to 1,057 in2020,with an average annual growth rate of 1.69%.The total number of employees of Du’an County People’s Hospital grew from 714 in 2015 to 871 in2020,with an average annual growth rate of 4.06%.The total number of employees of Dahua County People’s Hospital grew from 614 in 2015 to 730 in2020,with an average annual growth rate of 3.52%.The total number of employees of Fusui County People’s Hospital grew from 746 in 2015 to 871 in2020,with an average annual growth rate of 3.15%.In terms of total medical services: the number of emergency outpatient consultations at the Third People’s Hospital of Hechi increased from 409,852 in2015 to 435,792 in 2019,with a CAGR of 7.22%,and the number of inpatient surgical cases increased from 7,902 in 2015 to 10,163 in 2020,with a CAGR of1.16 %.The number of emergency outpatient visits of Dahua County People’s Hospital increased from 409,852 in 2015 to 484,145 in 2019,with an average annual growth rate of 5.52%,and the number of inpatient surgery cases increased from 5,512 in 2015 to 8,122 in 2019,with an average annual growth rate of 10.18%.The number of emergency outpatient visits at Du’an County People’s Hospital increased from 416,542 in 2015 to 592,257 in 2019,with an increase of 16.97 % Yo Y,and the number of inpatient surgery cases increased from 6,351 in 2015 to 4,679 in 2020,with an increase of-22.85 % Yo Y.The number of emergency outpatient visits at Fusui County People’s Hospital increased from 453,256 in 2015 to 565,120 in 2019,with a Yo Y increase of6.16 %,and the number of inpatient surgery cases increased from 4793 in 2015 to 4923 in 2019,with a Yo Y increase of 10.06 %.Medical service efficiency: the average hospitalization day of the Third People’s Hospital of Hechi City decreased from 7.85 days in 2015 to 7.58 days in 2020;the bed utilization rate decreased from 96.71% in 2015 to 88.84% in2020;the average hospitalization day of the People’s Hospital of Dahua County decreased from 7.85 days in 2015 to 7.58 days in 2020;the bed utilization rate decreased from 96.71% in 2015 to 88.84% in 2020;the average hospitalization day of Du’an County People’s Hospital rose from 6.05 days in 2015 to 6.45 days in 2020;the bed utilization rate fell from 92.5% in 2015 to 81.65% in 2020;the average hospitalization day of Fusui County People’s Hospital rose from 6.87 days in 2015 to 6.95 days;bed utilization rate decreased from 83.2% in 2015 to87.89% in 2020.Economic operation: the average cost per outpatient visit at Hechi Third People’s Hospital increased from 179 yuan in 2015 to 215 yuan in 2020,with an average annual growth rate of 3.78%,and the average cost per inpatient visit increased from 6,110 yuan in 2015 to 8,440 yuan in 2020,with an average annual growth rate of 6.68%;outpatient and emergency revenue increased from70,559,000 yuan in 2015 to 79.158 million yuan,with an average annual growth rate of 2.33%,and the total inpatient revenue increased from 180.206 million yuan in 2015 to 252.952 million yuan in 2020,with an average annual growth rate of 7.23%;the average cost per outpatient visit at Dahua County People’s Hospital increased from 151 yuan in 2015 to 188 yuan in 2020,with an average annual growth rate of 4.45%,and the average cost per inpatient visit increased from 4120 yuan to 5660 yuan in 2020,with an average annual growth rate of6.56%;the outpatient emergency revenue increased from 532.36 million yuan in2015 to 776.66 million yuan in 2020,with an average annual growth rate of7.85%,and the total inpatient revenue increased from 116.69 million yuan in2015 to 162.69 million yuan in 2020,with an average annual growth rate of6.79%.In terms of drug use: the drug ratio of the Third People’s Hospital of Hechi City decreased from 34.23% in 2015 to 24.43% in 2020.Dahua County People’s Hospital drug ratio from 30.05% in 2015 to 28.52% in 2020.Du’an County People’s Hospital drug ratio from 30.05% in 2015 to 28.52% in 2020.Fusui County People’s Hospital drug ratio from 20.00% in 2015 to 18.97% in2017.In addition,the sharing of resources between hospital x and the primary hospital after the implementation of the close medical association is as follows:from 2016 to 2020,hospital x has sent a total of 521 doctors to the recipient hospital,trained 262 doctors for refresher training for the primary level,trained122 general practitioners,performed a total of 12,799 cases of pathological diagnosis from 2016 to 2020,including 580 cases of difficult pathology and1,334 cases of freezing,a total of 297 charity clinics from 2016 to 2020,3011 lectures by experts,505 training of grassroots medical personnel,784 surgical demonstrations,and 156 new technologies and projects.Conclusion:(1)the operational effects of the hierarchical diagnosis and treatment system need to be further optimized;(2)many supporting measures for the implementation of the hierarchical diagnosis and treatment system need to be further improved;(3)the interest mechanisms of all parties involved in the hierarchical diagnosis and treatment system still need to be further weighed;and(4)the information interoperability mechanisms between the hierarchical institutions at the upper and lower levels need to be further strengthened.Recommendation:(1)clarifying the functional positioning of tertiary public hospitals is the prerequisite for accelerating the construction of the hierarchical diagnosis and treatment system;(2)strengthening the capability of primary medical services is the key to the success of the construction of the hierarchical diagnosis and treatment system;(3)optimizing the game of interests among institutions is the embodiment of the incentive mechanism of the hierarchical diagnosis and treatment system;(4)a good up-and-down linkage mechanism is the presentation of the effect of the hierarchical diagnosis and treatment system. |
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