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The construction of county medical service community (medical community) is an important measure for building a hierarchical and integrated medical and health service system. The article takes Yinzhou District of Ningbo city as an example to elaborate the strengths and weaknesses of the internal environment and the opportunities and challenges of the external conditions using SWOT analysis in the construction of county medical community, also put forward corresponding countermeasures and suggestions to provide reference for the further improvement.
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Objective:To analyze the current status of referral of stroke inpatients and explore the characteristics of the referral network in Changsha, for the reference to improve and promote the hierarchical medical system of stroke.Methods:Data of the inpatient medical record of stroke patients and the annual reports of medical institutions in Changsha in 2018 were collected from the health statistics network direct reporting system of Health Commission of Hunan province, for analysis of the referrals of inpatients in different medical institutions. Social network analysis was adopted to analyze the density, centrality and K-core of the referral network of stroke inpatients.Results:A total of 82 medical institutions for stroke inpatients were included with 2 859 referrals of patients. Most of the referrals were made between tertiary hospitals(1 515), especially within hospitals of a stroke alliance(1 123). The density of referral network was 0.613.Tertiary hospitals were in the center of the network, the entry points of secondary hospitals were in the center of the network and primary medical institutions were located at peripheral positions. Most of the tertiary hospitals in the 15-core(14, 72.68%), 12 of them were the units of Hunan Stroke Alliance.Conclusions:Tertiary hospitals played an important role in the region, secondary hospitals were able to receive patients referred by tertiary hospitals, but few patients were transferred to primary care institutions; The primary medical institutions failed to play due roles in the referral network. The establishment of stroke alliances could promote the cooperation of hospitals in the alliance, but the division of labor and cooperation among different levels of medical institutions in the region needed to be further optimized.
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In order to further promote hierarchical medical system and enhance the capacity of primary healthcare services, China began to build compact county medical community. At present, the development of China′s compact county community still exists such problems as the construction of service system, the basic institutional mechanism, the quality of supply capacity and the core guarantee mechanism. In order to solve the existing problems, the authors took Shaxian District of Sanming City, Fujian Province, Dancheng County of Zhoukou City, Henan Province, and Yangqu County, Taiyuan City, Shanxi Province as examples to summarize the experience of the advanced pilot areas of the policy. In the future, the construction of compact county community in China should be based on the construction of " single-core multi-layer" system, starting from the five levels of collaborative management, practical operation, system construction, basic guarantee and multi-party supervision, to comprehensively enhance the healthcare services, and finally achieve the goal of the strategy of hierarchical medical and Healthy China.
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Objective:To investigate the disease spectrum referred from the community health service centers to the district tertiary hospital in the region.Method:The data of the referred patients from the community health service centers to Shanghai Yangpu District Hospital-a tertiary hospital in the region from January 2016 to December 2019 were collected. The composition and characteristics of the disease spectrum of the referred patients were analyzed.Results:The number of patient visits to the community health service centers in the region was increased from 4 684 938 in 2016 to 4 776 921 in 2019. The number of patient referral from the community centers to Yangpu Hospital was increased from 3 125 in 2016 to 6 853 in 2019. There were total 18 308 patients referred in 4 years, including 8 012 males (43.8%) and 10 296 females (56.2%). The age range of referred patients was from 1 to 99 years, including 53 referred patients aged ≤ 18 (0.3%), 927 aged 19-39 (5.1%), 2 831 aged 40-59 (15.5%), 4 424 aged 60-79 (62.2%) and 1 209 aged ≥ 80 (17%). The top five systems of diseases, which accounted more than 60% of total diseases, were circulatory system, endocrine nutrition and metabolic system, urogenital system, eye and appendage, and digestive system. Compared with male patients, more female patients with urogenital diseases were referred.Conclusion:The referral rate of community health service centers were increased from 2016 to 2019. The referred patients cover all age groups, more frequently in age group 60-79. The diseases of referred patients cover all system, and are different between males and females.
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Objective:To explore the changes of disease structure in a tertiary general hospital during the COVID-19 pandemic.Methods:A database of 783 diagnosis-related groups(DRG) patients in a tertiary general hospital from 2017 to 2020 was used. The rank sum test was used to compare the number of patients among different years, and the Chi-square test was used to compare the composition of patients among different years. With the patient composition ratio as the main index, the thermal cluster analysis was used to analyze the changes of disease structure during the COVID-19 pandemic, from the perspectives of major diagnostic categories(MDC) and the key DRG(the number of patients in any year more than 2 000)respectively. All analyses were performed in R software, with P<0.05 indicating significance. Results:There were significant differences in the number and composition of patients in MDC groups and key DRG groups among different years( P<0.05). The results of thermal clustering analysis showed that the MDC composition of patients in 2020 was significantly different from those in 2017 to 2019; the 26 MDC groups were classified into four main categories. The results of thermal clustering analysis also showed that the DRG composition of patients in 2020 were significantly different from those in 2017 to 2019; The RU14 group and the other 19 key DRG groups were classified into different groups; and the other 19 key DRG groups except RU14 were classified into five main categories. Conclusions:The disease structure of tertiary general hospitals has changed significantly during the COVID-19 pandemic.
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Critical care medicine has developed rapidly and has become an indispensable comprehensive subject in clinical medicine at home and abroad.In recent years,the government has vigorously implemented the "Healthy China" strategy and strived to achieve a higher level of national health.The Henan Provincial People's Hospital has set up a network of interconnected "Wisdom · Critical Care Medicine Specialist League" to meet the major strategic needs of the country,and to play a role in attracting large hospitals to promote the sinking of quality medical resources and the improvement of grassroots service capabilities.Complementary advantages and resource sharing are conducive to achieve win-win cooperation and coordinated development between the third-grade class-A hospital and grassroots hospitals.
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Development of medical alliances is an important step and institutional innovation to deepen the healthcare reform.The authors analyzed the practice and experience in Fujian Provincial Hospital in this regard, and discussed the confusion and difficulties faced in the process.On such basis, they raised such proposals as transforming conception of the people, forming a multi-departmental coordination mechanism and policy superposition effect, building a sound medical alliance assessment system, and clarifying information construction standards, hence developing a new era of hierarchical medical system by means of developing medical alliances.
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Objective To analyze the patient information and hospitalization of non-local patients whose medical expenses will be directly settled with their local medical insurance network by a tertiary hospital in Tianjin, and to suggest on further development of direct settlement of medical insurance networking for non-local patients in Tianjin. Methods A retrospective analysis was made on the data of 1 068 non-local patients whose medical expenses were directly settled via medical insurance network from September 2017 to September 2018. Results The majority of non-local patients came from Hebei province, mostly over 51 years old; these inpatient focus on the renown key disciplines such as urology and cardiology;about a half of them were surgical patients; the proportion of patients with chronic diseases was high. These non-local patients in Tianjin feature higher age, more hospitalizations, lower self-paid expenses and lower overall hospitalization costs. Conclusions We should strictly control the referral system of non-local patients, strengthen medical support to areas of poor medical conditions, strengthen the hierarchical medical system; enhance the publicity of non-local patient online settlement and policy awareness, and simplify the filing process. It is also important to enhance network construction and data stability.
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" Day surgery hospital-community joint follow-up model " results newly from the deepening implementation of the hierarchical medical system policy. It is designed to follow up the patients discharged from hospital but not fully recovered in time to ensure the prevention of adverse events after surgery. It can also improve the quality and efficiency of follow-up, and ensure the safety and integrity of the whole day operation management. In this context, through a comparative study of 720 patients discharged from daytime surgery in the region, patients in the combined follow-up group were followed up by telephone on the 3rd day after the operation by nurses from the day surgery ward. On the 10th and 20th days after the operation, the family doctor from the community health service center will visit the patient at home and follow up the patient by telephone. One month later, the patient returned to the hospital for follow-up consultation. Follow-up results show day surgery hospital-community joint mode as a helpful aid in keeping track of the patients postoperative rehabilitation, reducing complications and handling in time, while improving the ambulatory surgery perioperative safety.
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Higher service efficiency and better medical experience are main goals of the healthcare system reform.The article explained the logical framework, main actions, initial results of the " one visit for all" reform, which aims at promoting the efficiency of medical services and management in Hangzhou.Policy suggestions are raised, namely involving more people into the governance mechanism, collaboratively optimizing the working process of medical staff, improving the information security mechanism, and perfecting the effectiveness evaluation system.These measures are designed to accelerate the construction of modern hospital management system, and to build a scientific and orderly hierarchical medical system.
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Digital healthcare empowers optimization of medical services.This article introduced the practices and achievements of Hangzhou in the following aspects: the construction of a hierarchical medical system guided by " people-oriented integrated service" ; development of the five digital platforms, namely regional health information platform, integrated medical care platform, remote consultation platform, intelligent supervision platform and doctor-patient remote interaction platform; development of " Smart Medicine" to promote institutional cooperation, service integration, management coordination, quality improvement and doctor-patient interaction.The paper also analyzed the supporting role of digital healthcare construction in promoting the hierarchical medical system, and put forward corresponding countermeasures and suggestions.
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Based on a sufficient analysis of the theoretical framework of " transformation learning collaboration" ( TLC ) and " people-centered and integrated health care " ( PCIC ) mode, this article introduced the main practices and achievements of " Hangzhou characteristics" countywide medical alliances, centering on TLC mode.Hangzhou takes the countywide medical alliance construction as a pilot, refers to the TLC model, and takes growth-oriented collaboration as the guidance, to promote responsibility sharing, benefit sharing, service integration and management collaboration.Guided by the PCIC model proposed by the World Health Organization, the city has established an integrated service model of hierarchical medical system-prevention-rehabilitation-aging care.The countywide medical alliance system framework features " 5 fields, unified leadership, unified culture, 6 supports, 3 tasks and TLC teams " , which may provide references for the coordinated and integrated development of such alliances.
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Objective To analyze the dilemmas of our hierarchical medical system, in order to seek a viable path for effective implementation.Methods Based on the Meter-horn model, six related factors were used, including policy standards and goals, policy resources, implementation methods, characteristics of the actuator, value orientation of the executive and the system environment, to analyze the dilemmas of the implementation of hierarchical medical system.Results This policy had not achieved the expected effect in the implementation process, which deviated from the original intention of policy designers to some extent. There exist the following setbacks for the roadblocks. For example, policy standard was ambiguous, the policy resources were insufficient, the execution method was not proper, the implementation mechanism was"criticized" , the implementation personnel value orientation was biased and the complex system environment.Conclusions All the factors involved in the implementation of the hierarchical medical policy affect each other.In this consideration, medical institutions at all levels and the relevant departments should coordinate and deal with the relationship between these six related factors, and timely take effective measures to amend and improve the policy, so as to ensure the orderly progress and long-term implementation of the hierarchical medical system.
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Active exploration for building a model of medical alliances fitting local needs, proves imperative for the functional positioning of medical institutions, promoting inter-institutional cooperation and enhancing the capacity of primary medical services. The authors described experiences and insights of the No.1 Affiliated Hospital and the People′s government of Quangang District in their partnership, and building a brand new model of medical alliance between a hospital and a local government. Also presented are characteristics of such a model, and analysis of operational data in benefiting the people. They held that such a partnership is a worthy attempt in the healthcare reform, by means of building medical alliances between local government and provincial hospitals. Such a practice can provide valuable references for promoting government-hospital synergy, elevating primary healthcare capacity and advancing the hierarchical medical system.
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With the progress of the hierarchical medical system, the top-level design for building medical alliances is exhibiting a clearer picture. The Chinese government sets about trying to build a grid-based medical system layout, covering from national, provincial, municipal, county, township, all the way to village level. Based on the analysis of regional grid-based medical systems in the United States, Switzerland, Singapore and Canada, the authors reviewed the development of grid-based health service system in China, and found out key roadblocks for grid-based medical alliances. These problems include the organizational structure, service content, management mechanism, payment system and other aspects, and corresponding countermeasures and suggestions were proposed in the end.
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The reform of medical and healthcare system is the inevitable process for the medical and healthcare developing in China.The main contents of the reform include establishing a scientific and reasonable system of medical treatment and classification,a scientific and effective modern hospital management system,a universal medical insurance system with efficient operation,a standardized and orderly drugs and medical equipment supply,and a strict and standardized comprehensive supervision system.The national big data platform for medical and healthcare management can play an important role in the reform of medical and healthcare system in China.First,it can help to improve the treatment effect of the disease,improve the prognosis,reduce the morbidity and mortality rate,and improve the health level.Second,it can effectively control the risk of medical insurance funds,and reduce the fund operational risk.Third,it can improve the efficiency of healthcare services and medical service resource utilization,so as to reduce medical costs.Fourth,it can help to build the link between residents and family doctors and hospitals,and to promote the medical consortium and hierarchical medical system through electronic signatures,online booking,telemedicine,real-time health monitoring,and two-way referral.Fifth,it can help to establish a medicine and medical equipment circulation system with the characteristics of source-traceable,full controllable,risk-preventable,responsibility-assessable,performance-assessable,and open-and-transparent.Finally,it can effectively improve the quality evaluation and regulatory level of the medical system in China.The existing problems in medical reform in China were introduced,and the relationship and the significance of the national big data platform for medical and healthcare management to medical and healthcare system reform were analyzed.
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Objective To investigate the health services use of hierarchical medical system in elderly patients with type 2 diabetes mellitus in the community and to provide information for improving hierarchical medical system.Methods A survey of 684 T2DM patients aged 60 years and older was conducted in the Hua Mu Community Health Service Center in Shanghai from September 2014 to August 2016.And the data about health services visits for T2DM and its complications were collected in the latest one year.Based on different habits for patients receiving medical service,all patients were divided into two groups:the hierarchical treatment group and control group.All clinical and follow-up data were compared between two groups.Results 368 patients (53.8 ％)took on a priority in clinical visits to community health service center.There were no significant differences in age,gender,education,marriage,income,health insurance and duration of diabetes between the two groups(all P＞0.05).The acquired written health information about diet and exercise were much more in hierarchical treatment group than in the control group during one year.Although the rate of screening of diabetic nephropathy was similar between the two groups (P ＞ 0.05),the rate for retinopathy,neuropathy,vascular and diabetic foot was lower in hierarchical treatment group than in control group (all P ＜ 0.05).Moreover,the levels of glycosylated hemoglobin,urine albumin-to-creatinine ratio,total cholesterol,triglyceride,low-density lipoprotein cholesterol were similar between the two groups (all P＞0.05),but the level of high-density lipoprotein cholesterol in hierarchical treatment group was lower(P＜0.05).Furthermore,the rates of emergency visiting and hospitalization were lower in hierarchical treatment group than in the control group(both P＜0.001),and there was no significant difference in the average length of hospital stay between two groups (P ＞ 0.05).Conclusions Hierarchical medical system is favourable for the rational use of medical resources,but it is not yet quite perfect.Further improvements are still needed.
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Objective: To analyze the change in community first diagnosis and two-way referral rate under the condition of the regional longitudinal medical consortium implementation in the country at large. According to the simulation results,some suggestions for hierarchical medical system were put forward. Methods : The community first diagnosis and two-way referral rates were determined using the literature meta-analysis, and were simulated under different conditions by means of the system dynamics. Results :The analysis results confirmed that simply increasing the financial subsidies can increase the community first diagnosis rate within a range from 0.08％ to 0. 17％. For in case increases are made by the government in technical financial input to enhance the technical level of the community health service centers and in compensatory financial input to reduce the higher hospitals dependence on the light disease, results showed that the lower conversion rate increased within the range of 0.33％～0.45％ in terms of the two-way referral rating. On the contrary, when technical financial input is increased to improve the technical level of community health service centers, the rate of change was in the range of 7.52％ '- 12.61％ - Conclusions : Firstly, the diversified strategy should be used to promote the achievement of graded diagnosis and treatment. Secondly, the Health Commission plays a key role in the promotion of themedical consortiumconstruction. Thirdly, medical insurance reimbursement differential strategy should be implemented and the supply-side reform should be strengthened. At last,attention should be paid to the rational development of existing referrals, especially the upper and lower ones.
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Objective: To conduct a two-dimensional analysis on the key issues that affect the promotion of hierarchical medical system in China, whereby the two dimensions being taken into consideration are the imminence and solvability of the issue, so as to provide reference for the future decision-making on the policy formulation. Methods : 77 papers were systematically collected and 20 issues that may be hindering the hierarchical medical system in China were summarized through the literature review. The imminence and solvability of each issue under cause were evaluated through Delphi method and analytic hierarchy process (AHP). Finally,the key issues hobbling hierarchical medical system were listed by using the variation coefficient method. Results : Research results confirmed that the three issues found to be the key issues include the acute shortage and insufficient service capacity of general practitioners,imperfect physician multi-point practice system which hinders the free flow of doctors, and the current financial input mechanism which is not conducive to the implementation of graded diagnosis and treatment in China. Conclusion : In order to promote hierarchical medical system, suggested are the general practice education reform, stopping the policy restrictions to the doctors' free flow,strongly advocating for the development of primary private healthcare institutions,and constructing the cooperative and restrictive relationship between primary healthcare institutions and higher level hospitals.
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At present,the functional positioning,service capabilities and resource allocation of various medical institutions differs in China,the tertiary public hospitals,which are rich in high-quality resources,are playing a significant role in integrating medical resources,improving the accessibility and affordability of services and achieving the Chinese national health goal.Through the analysis of the importance and key problems of leading hospitals in a variety of medical alliance,the paper explores the basic ideas and pathways of public hospitals' leading role in various forms of medical alliances.