| Objective With the increasing aging of China’s population,the improvement of living standards and the change of disease spectrum,the reality of the shortage of medical and health resources and the shortage of high-quality resources has become increasingly prominent.The contradiction between people’s growing demand for differentiated medical and health services and the current supply shortage has become increasingly prominent.In addition to the current situation of inverted triangular distribution of medical resources in China,high-quality resources are gathered in Class III hospitals,and a large number of patients with common and chronic diseases flow into Class III hospitals,which not only wastes high-quality medical resources,but also is the deepseated cause of doctor-patient conflicts and disputes,reducing the accessibility and continuity of medical and health services.As the core link of hierarchical diagnosis and treatment,two-way referral is the breakthrough to effectively solve the problem of difficult and expensive medical treatment,and plays an important role in optimizing and improving the allocation and utilization of medical and health resources,reducing the medical costs and the economic burden of patients’ diseases,improving the continuity of diagnosis and treatment services and patient satisfaction,alleviating the contradictions and disputes between doctors and patients,and promoting the efficient operation of the medical and health system.Since the first two-way referral in 1997,the country has continuously strengthened its attention and investment in the integrated medical and health service system.The two-way referral has achieved phased results,but it still faces obstacles such as turning up and down,siphon effect of large hospitals,weak grass-roots capacity,maladaptation of the medical insurance system,and imperfect benefit matching mechanism.Therefore,this study aims to explore the existing problems and influencing factors by studying the implementation status of twoway referral in Anhui Province’s current close urban medical association,with a view to providing a reference basis for further promoting the graded diagnosis and treatment work,and providing inspiration for creating an ideal medical service model of "minor disease in the community,major disease in the hospital,and rehabilitation back to the community".MethodsThrough literature review,this study combed,summarized and summarized the current literature,policies and related reports on two-way referral,and after several rounds of discussion by experts,designed and developed a two-way referral questionnaire for medical staff of hospitals led by the medical consortium,medical staff of primary medical and health institutions and community residents.Using multi-stage stratified random sampling,combined with the level of social and economic development,a field survey was carried out in a close urban medical union in central,northern and southern Anhui.Interview key insiders to understand the progress of two-way referral work of the close urban medical union in the survey area;The questionnaire was used to investigate the cognition,satisfaction and willingness of referral of medical staff and community residents to the two-way referral system.The data were analyzed by general descriptive analysis,chi-square test and binary logistic regression.Results(1)The current situation of the development of Anhui tight urban medical association in the perspective of symbiosis theory:(1)The release of a series of rules,regulations and documents such as the symbiosis environment "Anhui Provincial Health and Health Commission’s Implementation Opinions on Developing Graded Diagnosis and Treatment" has built a reasonable top-level framework for the symbiosis system of twoway referral of Anhui tight urban medical association and created a good policy level symbiosis environment.In 2019,the annual growth rate of patients transferred from medical institutions in the province increased by 6.12% over the same period,and the annual growth rate of patients transferred from medical institutions decreased by 4.65%over the same period,showing a change of "decrease in upward transfer and increase in downward transfer".(2)The symbiosis unit is located in the city,with the threelevel public general hospital as the leader,driving the community health service center,and building a close urban medical union.By the end of 2021,Anhui Province has established 34 close urban medical consortia,covering 12 prefectures and cities,and the expert resources of large hospitals have effectively sunk.(3)Symbiosis mode: the two-way referral symbiosis mode of Anhui Province’s close-type urban medical association.Through the grid layout and the construction path of "five guarantees and ten unifications",the close-type urban medical association is built to create the twoway referral symbiosis mode of Anhui Province’s close-type urban medical association.(2)Research on two-way referral providers in the survey area(core hospital medical staff):(1)cognition: 85.3% of core hospital medical staff understand two-way referral work;67.3% of the medical staff believed that the two-way referral system was necessary;87.3% of medical staff believed that the maximum benefit of two-way referral could make reasonable use of health resources;Patients’ distrust of the level of basic medical technology is considered to be the most important factor hindering the implementation of two-way referral.(2)Participation: 83.7% of the medical staff of the core hospital have received transferred patients;68.7% of medical staff have transferred patients to the grass-roots level;More than half of the medical staff think that the cooperation between the referral patients and the receiving unit is general or poor.(3)Willingness to transfer and influencing factors: 74.8% of medical staff are willing to transfer eligible patients to the grass-roots level;The factors that influence the willingness of medical staff in core hospitals to transfer patients are the location,training,cognitive necessity,hospital encouragement to transfer,the influence of referral on the source of disease,cumbersome referral procedures and imperfect information system.(3)Research on two-way referral providers in the survey area(medical staff of community health service center):(1)cognition: 87.8% of primary medical staff understand two-way referral work;75.3% of the medical staff believed that the twoway referral system was necessary;83.0% of the medical staff believed that the maximum benefit of two-way referral could facilitate the patient’s medical treatment;The limited level of primary medical and health services is considered to be the most important factor hindering the implementation of two-way referral.(2)Participation:58.3% of primary medical staff have received transferred patients;67.9% of medical staff have transferred patients to core hospitals;More than half of the medical staff think that the cooperation between the referral patients and the receiving unit is good.(3)Willingness to transfer patients and its influencing factors: 61.3% of primary medical staff are willing to accept patients transferred from superior hospitals;Years of work,monthly income,understanding of two-way referral,publicity,lack of drugs at the grass-roots level,mistrust of referral patients at the grass-roots level,the impact of referral on doctors’ income and cumbersome referral procedures are the factors affecting the willingness of grass-roots medical staff to accept referral patients.(4)The research on the demanders of two-way referral in the survey area:(1)cognition:83.0% of community residents have not heard of two-way referral system;57.3% of the community residents believed that the two-way referral system was necessary;The main channel for community residents to understand two-way referral is the introduction of hospital doctors and family and friends.(2)Participation: only 9.7% of the community residents said that they and their families had referral experience,and22.0% of the community residents were not satisfied with the referral experience;Long waiting time for referral,cumbersome procedures and lack of understanding of the referral process and standards are considered as the main reasons for dissatisfaction.(3)The willingness and influencing factors of downward transfer: only 46.8% of community residents are willing to downward transfer to the grass-roots level;Cognition of the necessity of referral,the quality of drugs at the grass-roots level,trust in the medical technology at the grass-roots level and the degree of self-perceived illness are the influencing factors of whether community residents are willing to transfer to the grass-roots level.ConclusionAnhui Province attaches great importance to hierarchical diagnosis and treatment and two-way referral.By actively formulating policies and promoting relevant measures,it has established a collaborative and high-quality symbiotic unit,created a positive symbiotic environment and built a close,symmetrical and mutually beneficial symbiotic model.Relying on the construction of a close urban medical union,the service capacity of the community health service center has been improved,and the trend of medical treatment for residents in all districts has gradually conformed to the functional orientation of medical institutions,At the same time,relevant policies and measures were introduced,such as the implementation of the graded management of medical charges and the differential payment system of medical insurance to promote the first diagnosis in the community.The study also learned about the willingness of doctors and patients to transfer down and the influencing factors.On the whole,the willingness of doctors and patients to transfer down is not high.Although the factors that affect the willingness of medical staff in core hospitals to transfer patients down and the willingness of community doctors to accept transferred patients are different,they should all pay more attention to these factors,including geographical factors,income situation,whether to understand two-way referral,whether to train,publicity,whether the hospital encourages the transfer down Whether the referral procedures are complicated,whether the information system is sound,and whether the patients trust the grass-roots level.Based on the analysis of the interview and survey results,the research summarized the difficulties in the implementation of two-way referral work of the medical union in Anhui Province,which is a close city.The cognitive level of both doctors and patients on the two-way referral system needs to be improved;The promotion measures of the two-way referral system within the medical union of the compact city still need to be strengthened;The level of basic medical and health services needs to be improved;Clear and clear referral guidelines are relatively lacking,and the power of referral in superior hospitals is insufficient;The referral mode is immature and the information system is imperfect;Publicity needs to be strengthened.In view of the above existing problems,the following policy suggestions are put forward through sorting out the literature,policy documents and the results of the interview questionnaire: straighten out the functional orientation and strengthen the grass-roots foundation;Unify the referral standard and optimize the referral process;Government-led,improve supporting measures and policy support for two-way referral,and strengthen supervision and management;Strengthen the construction of a close urban medical union and optimize the two-way referral operation mechanism;Actively propagandize and guide and improve the awareness of doctor-patient referral. |
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