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Medical mutual aid is an important component of multi-level medical security system. West China Second University Hospital of Sichuan University led the establishment of the pediatric specialty alliance " West China Women and Children Alliance". Based on customized and inclusive mutual insurance product " Family Doctor Mutual Aid Plan", the alliance implemented key links such as mutual aid product forms, patient risk protection, institutional financing and hematopoiesis, and distribution of benefits to all parties, explored innovative mutual aid funding, payment, and incentive mechanisms, forming a closed-loop pediatric tiered diagnosis and treatment service system with the Mutual Aid Plan as the core. This system operated continuously under the " Four-in-One" framework, stimulating the integration of medical insurance and service supply systems while enhancing the synergistic effect between mutual insurance and social security. It has formed a distinctive health-centered multi-level medical security system within the alliance, and could provide reference for the construction and exploration of hierarchical diagnosis and treatment system.
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As an important healthcare service to cope with the aging population and slow disease characterization,the quality and development mode of the successive healthcare service has gradually attracted attention as to how to adapt to the existing hierarchical diagnosis and treatment system.It will sort out the supportive policies and development status of the successive medical services un-der China's hierarchical diagnosis and treatment system,and find out the problems in the development of the successive medical ser-vices under the hierarchical diagnosis and treatment system in the new period,in order to provide references and suggestions for the further sustainable development of the successive medical services in China.
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Objective To understand the status quo of hierarchical diagnosis and treatment effect of medical alliance in Beijing and explore the influencing factors.Methods The convenience sampling method was used to select 26 vertical medical alliances,and the weighted TOPSIS method was used in combination with the index system established in the previous study to evaluate the effect of hierarchical diagnosis and treatment.The factors influencing the effect of hierarchical diagnosis and treatment in medical alliances were summarized through interviews with insiders,and the rank sum test was used to explore the factors influencing the effect of hierarchical diagnosis and treatment in medical alliances.Results The medical alliance B,A2 and A3 ranked high,and the implementation effect was relatively good in the four dimensions of"primary care first consultation,dual-way referral,acute and slow treatment,and vertical linkage";The C2,A8 and F2 medical alliances ranked low,and the implementation effect in the dimensions of"dual-way referral","acute and slow treatment"and"vertical linkage"was significantly lower than that of other medical alliances.The analysis results showed that the differences in the support intensity and core hospital level of different medical alliances were statistically significant(P＜0.05),which affected the hierarchical diagnosis and treatment effect of medical alliances.Conclusion While strengthening the information construction and improving the initiative of grassroots and the signing rate of family doctors,it is necessary to improve the support of core hospitals to promote the sinking of resources.Core hospitals should optimize resource allocation according to local conditions and promote hierarchical diagnosis and treatment.
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Objective To develop and validate a questionnaire for assessing the synergistic effects of physician col-laboration within a tiered healthcare system,dissect its structural dimensions,and explore the internal logical rela-tionships among these dimensions.Methods Literature review and focus group discussions were employed to clarify the conceptual framework and components of the synergistic effects of physician collaboration in a tiered healthcare system,leading to the development of the questionnaire.Multi-stage sampling was used to survey 1 959 physi-cians.Results The questionnaire for assessing physician collaborative synergy effects consists of four dimensions:col-laborative cognition,collaborative trust,collaborative willingness,and collaborative behavior,comprising 10 items in total.The overall Cronbach's coefficient and the coefficients for four dimensions were all above 0.7.Exploratory factor analysis results extracted four common factors,with a cumulative variance contribution rate of 86.7％.Confirmatory factor analysis revealed that the composite reliability of the four dimensions of the questionnaire was above 0.7,and the average variance extracted was above 0.5.Collaborative cognition influenced collaborative behavior through the chain-mediating roles of collaborative trust and collaborative willingness.Conclusion The developed questionnaire for assessing the synergistic effects of physician collaboration in a tiered healthcare system has good reliability and validity.Its dimensions fit well with the interrelated structure of"knowledge","emotion","intention"and"action",making it a suitable reference tool for evaluating the extent and effectiveness of physician collaboration across different medical institutions within a tiered healthcare system.
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The shortage of pediatric resources and inadequate diagnosis and treatment capacity in primary hospitals are key problems for implementing hierarchic care system of children's diseases. To solve this difficulty, Zhejiang province has constructed a three-stage standardized pattern for pediatric diagnosis and treatment ability training for primary doctors, which integrates training promotion, continuing education and practice output. Training promotion includes the training courses, theoretical examination, and the certification of Zhejiang Pediatric Alliance. Continuing education includes mobile teaching resource library and online regular Q&A. Practical output includes graded diagnosis and treatment of children's diseases and public lectures. From 2018 to 2021, a total of 1 418 trainees participated in 7 training sessions, 327 of whom passed the examination. Finally, 53 participants completed the certification of Zhejiang Pediatric Alliance and were included in the hierarchical diagnosis and treatment system for children in Zhejiang Province, expanding the coverage of hierarchical diagnosis and treatment from 32 institutions in 24 districts to 73 medical institutions in 38 districts. Members of the alliance completed 40 public lectures, with a total audience of 13 233. The three-stage standardized pattern continuously improves the comprehensive ability of primary doctors by means of multi-forms, standardization and continuity. We hope our experience can provide a reference for the training of primary doctors and the construction of hierarchical diagnosis and treatment system in various regions.
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Objective:To systematically evaluate the effect of on-the-job training of primary health workers in Pukou District, Nanjing City by using the Kirkpatrick's four-level model of evaluation, and to provide a basis for the design of on-the-job training programs for primary health workers.Methods:A questionnaire was conducted to investigate the basic information, training status, and training effects of the staff in all primary medical and health service institutions in Pukou District. A total of 428 valid questionnaires were collected. SPSS 16.0 software was used for statistical analysis, binary or ordinal Logistic regression was used to screen related factors.Results:In the response evaluation, 49.6% (192/387) of trainees thought that it was meaningful to participate in the training; in the learning evaluation, 51.4% (220/428) understood the frontier knowledge of their profession; in the behavior evaluation, 40.3% (156/387) had widely used the content of the training; in the result evaluation, 41.3% (177/428) said that the quality of their work was very high. Comprehensively, training frequency, training duration, professional category and professional title were the influencing factors of training effect.Conclusion:Overall, the training effect of primary health workers is not satisfactory. In a word, increasing the frequency of training, enhancing health personnel's awareness of the importance of training, and extending the duration of training can effectively improve the training effect.
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Purpose/Significance With regional collaboration as the core,the study explores an efficient,convenient and stand-ardized two-way referral service mode,further implements the hierarchical diagnosis and treatment system,and realizes the ration-al allocation of medical resources.Method/Process Combined with the"internet+",a two-way referral cloud platform is built to realize the interconnection and information sharing between the referral business and the hospital business.Result/Conclusion The construction of the two-way referral cloud platform has promoted the standardization and convenience of referral process and im-proved the satisfaction of doctors and patients.The two-way referral service mode based on regional collaboration promotes the in-tegration of medical resources,improves the medical service capacity of medical alliances,and improves the medical experience of referral patients.
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In order to compare the setting of difference coefficients in DRG point payment in different cities in Zhejiang province, the implementation rules of DRG point payment issued by 11 cities in Zhejiang province were comprehensively analyzed. It was found that the difference coefficients in different cities could be divided into three categories, including hospital coefficients alone, hospital coefficients and grade coefficients weighted, and weighted by hospital coefficients, grade coefficients, personal burden levels, case mix indexes, and head-to-time ratio. Its setting differences included four aspects: connotation composition, weight distribution, threshold value, and classification of medical institutions. The authors suggested that the adjustment cycle should be set scientifically to dynamically adjust the difference coefficient, and the scientific setting of the difference coefficient should be promoted through provincial coordination.
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Hierarchical diagnosis and treatment system is an important measure to rationally allocate medical resources and promote the homogenization of basic medical services. The medical alliance is an important service mode and service system of hierarchical diagnosis and treatment, whose role is to perfect the up-down linkage and meet the patient′s medical needs. Informatization construction is an important starting point to promote the services of the medical alliance. In order to solve the problem of connectivity, the medical alliance needs to establish a regional referral platform and realize the integrated service of all medical institutions. Renji Hospital, Shanghai Jiaotong University School of Medicine, has built a blockchain based referral system for hierarchical diagnosis and treatment, incorporating the S2B2C mode concept, and using the traceability, tamper proof and distributed accounting features of blockchain technology, realized independent storage of data in hospitals, realized real-time information sharing and interconnection, and provided a feasible solution for medical alliance management.
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Objective:To analyze the current situation and problems of cross-provincial medical treatment for children in Shandong province, and put forward corresponding countermeasures.Methods:The FUTang Updating medical REcords(FUTURE)database established by Futang Children′s Medical Development Research Center was selected to extract the data of 0-14 years old children who were discharged outside Shandong province from January 1, 2019 to December 31, 2020 and whose current address was in Shandong province, and the data of hospitalized children in a children′s hospital in Shandong province during the same period were selected for comparison. The SPSS 22.0 software was used to establish the database, and statistics and analysis were made on the number of cases, main flow direction, departments, types of diseases and hospitalization cost of children.Results:A total of 13 071 cases accepted cross-provincial medical treatment were included, and the main flow of medical treatment was Beijing Children′s Hospital. The data of 87 742 children admitted to a children′s hospital in Shandong province at the same time were included. The proportion of female and school-age children in children accepted cross-provincial medical treatment was higher than that of local patients, and the hospitalization cost was higher than that of local patients. The main diseases for children seeking medical treatment outside the province were tumors, immune diseases and other serious diseases or chronic diseases, while the main diseases for children seeking medical treatment in the province were respiratory diseases such as pneumonia.Conclusions:The proportion of tumors and immune diseases among children aged 0-14 years accepted cross-provincial medical treatment is relatively high. Hospitals in Shandong province should pay attention to the construction of key specialties, actively develop new technologies and new businesses, and enhance the core competitiveness of hospitals. At the same time, we should improve the medical service system and guide patients to seek medical care reasonably through policies.
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Objective:To evaluate the effect of hierarchical diagnosis and treatment model of childhood bronchial asthma in Shanghai Pudong New Area.Methods:According to the principle of proximity, children aged 6 months-17 years who were diagnosed with bronchial asthma at Shanghai Children′s Medical Center from July 2016 to May 2017 were divided into two cohorts: the specialized hospital group and the community hospital group.Twelve months of treatment and follow-up were conducted.The asthma control level, Childhood Asthma Control Test (C-ACT) score, medication adherence and health economic indicators were collected.Results:A total of 524 children were included for data analysis and divided into the specialized hospital group (300 cases) and the community hospital group (224 cases). According to the Global Initiative for Asthma(GINA) criteria, there was no statistical difference in monthly asthma control level between the two groups (all P>0.05). In the 12 th month, the well-controlled rate of the specialized hospital group increased by 12.4% ( P<0.01), and that of the community hospital group increased by 22.9% ( P= 0.015). According to the C-ACT criteria, there was no statistical difference in the monthly well-controlled rate between the two groups (all P>0.05), and the rate maintained an upward trend.The rates of patients with good compliance in the specialized hospital group and the community hospital group at the 12 th month of hierarchical diagnosis and treatment were 78.3%(235/300 cases) and 75.0%(168/224 cases), respectively, and the difference was not statistically significant ( P=0.370). After 12 months of hierarchical diagnosis and treatment, the number of asthma attacks were 1.0 and 2.0 ( P=0.269), and the hospitalization rates for asthma were 3.0%(9/300 cases) and 4.9%(11/224 cases), respectively in the specialized hospital group and the community hospital group, and the diffe-rence was not statistically significant ( P=0.259); the number of respiratory infections in the specialized hospital group (2.0 times) was lower than that in the community hospital group (3.0 times), and the total cost of treatment in the community hospital group (2 471.5 Yuan) was lower than that in the specialized hospital group (3 445.5 Yuan), and the difference was statistically significant ( Z=-3.308, -3.336, all P<0.01). Twelve months after hierarchical diagnosis and treatment, the number of asthma attacks, the number of respiratory infections and the hospitalization rate for asthma in the two groups were all lower than those in the first 12 months of hierarchical diagnosis and treatment, and the difference was statistically significant (all P<0.01). Conclusions:Hierarchical diagnosis and treatment model of childhood asthma in Shanghai Pudong New Area can improve asthma control level, C-ACT score and asthma medication adherence, and enhance health economic benefits, thus it′s an effective way to manage childhood asthma.
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Construction of medical alliances could help structural adjustment of medical resources, promote the shift of medical and health investment to primary level, improve the overall effectiveness of the medical service system, and better meet the health needs of the people. Guangzhou has established a multi-form and multi-level medical alliance system in accordance with local conditions. According to the distribution characteristics of medical resources in the districts under the jurisdiction of Guangzhou, these districts were divided into areas of controlled development, those of stable development and those of encouraged development. Different strategies were taken for various medical alliances. Advantages of traditional Chinese medicine were given full play in community health management and elderly care services, alliance of traditional Chinese medicine specialists was established to provide residents with continuous medical and health services. An appropriate medical insurance payment system was established to promote the implementation of the hierarchical diagnosis and treatment system. However, there were still such problems as unbalanced distribution of medical resources, insufficient leverage role played by medical insurances, and rooms of improvement in the ability of primary medical services.
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Reasonable intra-hospital hierarchical diagnosis and treatment system will effectively guide the patients to see a doctor on demand and improve the efficiency of medical services. Beijing Tongren Hospital, Capital Medical University, has explored the intra-hospital hierarchical diagnosis and treatment system depending on different situatioins such as for new patients, subsequent visit patient, and the same patients with different clinical stage. Through establishing a series of intra-hospital hierarchical diagnosis and treatment modes, such as the well-known expert team, the outpatient service for specialized diseases, the multidisciplinary outpatient service for complex diseases, the nursing service, and the pharmaceutical care service, the outpatients could be oriented by specialties and disciplines and graded by the complexity in diagnosis and treatment of diseases. Relying on the appointment methods such as referral and revisit to open up the information channel, it can optimize the time cost and economic cost of patients, reflect the functional positioning of the tertiary hospitals, and improve patients′ sense of medical access and happiness.
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" Two-way referral, and synergy between the tertiary hospitals and primary institutions" is the core measure for promoting hierarchical diagnosis and treatment in the region. The authors introduced the exploration and practice of constructing a two-way referral path in the medical alliance based on telemedicine in West China Second University Hospital of Sichuan University. As of May 2021, the hospital had established a two-way referral path with 52 member hospitals of the medical alliance. By clarifying the functionality and positioning of these institutions, optimizing work processes and IT support, building the mechanism of referral and liaison, and that of appraisal as support, these efforts had achieved progresses in such fields as innovative medical service modes, lean management of referral processes, and promotion of hierarchical diagnosis and treatment system building.
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From January 2016 to June 2017, 1002 outpatients with T2DM were recruited in Chuiyangliu Hospital (core hospital) and eleven community health service centers in Chaoyang district in Beijing. A questionnaire survey was conducted, the survey items included demographic information, complications of T2DM, comorbidities and status of treatments. Among 1002 patients,there were 525 cases from the Southern Medical Consortium core hospital and 477 from the Southern Medical Consortium community health centers. The control rates of glycosylated hemoglobin, fasting blood glucose, 2 h postprandial glucose were 54.1％, 49.5％ and 54.6％, respectively. The blood glucose control rates in lifestyle intervention, single OAD and multiple OAD groups of core hospital were all higher than those in corresponding groups of community health centers (P<0.05). There were 115 patients managed with lifestyle interventions only and 887 patients with medications, in whom 533 were treated with oral antidiabetic drugs (OAD) and 354 cases were treated with insulin+OAD. The use rates of metformin in the core hospital and in community health service centers were 58.3％and 35.4％, the use rates of insulin were 48.4％and 24.2％, respectively. The blood sugar control of patients in community health centers is less satisfactory than that in core hospital of Chaoyang District South Medical Consortium in Beijing. The communication and cooperation between core hospitals and community health service centers should be further strengthened for better management of T2DM patients.
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From January 2016 to June 2017, 1 002 outpatients with T2DM were recruited in Chuiyangliu Hospital (core hospital) and eleven community health service centers in Chaoyang district in Beijing. A questionnaire survey was conducted, the survey items included demographic information, complications of T2DM, comorbidities and status of treatments. Among 1 002 patients, there were 525 cases from the Southern Medical Consortium core hospital and 477 from the Southern Medical Consortium community health centers. The control rates of glycosylated hemoglobin, fasting blood glucose, 2 h postprandial glucose were 54.1%, 49.5% and 54.6%, respectively. The blood glucose control rates in lifestyle intervention, single OAD and multiple OAD groups of core hospital were all higher than those in corresponding groups of community health centers (P<0.05). There were 115 patients managed with lifestyle interventions only and 887 patients with medications, in whom 533 were treated with oral antidiabetic drugs (OAD) and 354 cases were treated with insulin+OAD. The use rates of metformin in the core hospital and in community health service centers were 58.3% and 35.4%, the use rates of insulin were 48.4% and 24.2%, respectively. The blood sugar control of patients in community health centers is less satisfactory than that in core hospital of Chaoyang District South Medical Consortium in Beijing. The communication and cooperation between core hospitals and community health service centers should be further strengthened for better management of T2DM patients.
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Intra-abdominal infections(IAIs)is common in the clinic which includes a variety of pathological conditions,ranging from uncomplicated appendicitis to fecal peritonitis.IAIs can be classified as healthcare-associated IAIs and community-acquired IAIs according to the circumstance of origin.IAIs can be also classified as uncomplicated IAIs and complicated IAIs according to the extent of infection.However,the circumstance of origin and extent of infection can't predict the therapy difficulty and clinical outcome.So,the authors first propose the new concept of "pan-complicated IAIs" and elaborate its clinical significance which may evoke the interest of clinicians to pay close attention to the diagnosis and treatment of IAIs.
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An information system for "Internet+" hierarchical diagnosis and treatment was constructed with pa-tients as its center,with clinical information system as its basis,and with solution of difficulties in implementation of "Internet+" hierarchical diagnosis and treatment as its guidance. Its three key modules, namely online service module,data center module and off-line management module,were designed and analyzed,which helps the preci-sion match of resources and demands for the"Internet+" hierarchical diagnosis and treatment,promotes the vertical flow of good medical resources and improves the grass-root service level and efficiency.
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Hierarchical diagnosis and treatment is an effective way to "optimize and reconstruct medical and health service system" and solve the problems of "difficulty and expensiveness of getting medical treatment". At present, the hierarchical diagnosis and treatment still exists many problems in the process of practice, and the solu-tion of these problems not only requires government departments to do the top-level supporting policies, but also needs the medical institutions at all levels to change their thinking mode and innovate the appropriate hierarchical diagnosis and treatment system. This paper analyzed the dilemma of hierarchical diagnosis and treatment in China from the aspects of medical alliance operation mechanism, medical insurance system, physician multi-point occu-pation, medical resource allocation and medical information sharing and so on, and put forward corresponding countermeasures.
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Through screening of the literature,published time,published journals,research sites,research objects,research perspectives,influencing factors and countermeasures were listed by multi angle analysis of the bibliometrics method.The results show that the research on influencing factors of patients' selection of institutions in China has reached a certain level,but there are still some deficiencies.Follow-up studies need to define the following points which include the research heat is strongly related with the policy,the research of the patient's referral influencing factors should be strengthened,the depth of research needs to be improved,and the patients is the foundation of the countermeasures.