基层照护视角下病人就诊体验评价及与健康自评、满意度的关系研究
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摘要
研究背景
随着经济社会全面发展,西藏的医疗卫生事业也取得重大成就,卫生基础设施不断完善,以拉萨为中心辐射全区城乡的医疗卫生服务网基本形成。农牧区医疗制度全面建立,实现医疗制度全覆盖,人均期望寿命从和平解放初期的35.5岁提高到现在的67岁,孕产妇和婴儿死亡率分别比和平解放前下降28.6倍和20.7倍。国际上大量研究证明良好的基层照护(Primary Care)可显著提高人群健康状况,西藏的卫生体系也是以基层照护为基础。因此,西藏健康状况的巨大改善应该源自于其以基层照护为重点的卫生体系建设。
在西藏,绝大多数地区级医院为二级医院或一级医院,县级医院中一半左右为一级医院、一半左右未评级,地区级和县级医院功能不完善,主要为当地居民提供常见病、多发病的诊疗工作,兼顾预防、保健、康复功能。西藏幅员辽阔,地理可及性严重影响了病人的就诊选择,加之西藏未建立分级诊疗制度,因此,当居民产生基层照护需求时,往往选择最近的医疗机构就诊。因此,地区级医院和县级医院也是西藏重要的基层照护提供者。此外,传统的藏医药也深受广大藏区群众信赖,藏医医疗机构也是广大藏区群众就诊的首选,因此各级藏医医疗机构也成为西藏基层照护的一个主要提供者。根据相关资料估计,2012年地区级医院、县级医院、乡镇卫生院诊疗人次数分别为90万、240万、340万,藏医医疗机构就诊人次数达到90万。
随着“以病人为中心”理念的在我国的逐步深入,我国也越来越重视根据病人需求,“采用自下而上”的方式改革其卫生服务提供模式,加强基层照护体系建设无疑将会成为改革的一个目标。基层照护是以“病人为中心’(Patient-Centred Care)的照护服务,病人就诊体验(Patient Experience)是测量“以病人为中心”的一个重要指标,也是美国医学研究所建议的卫生服务质量的一个目标,主要应用于基层照护机构中(Primary Care Settings)。随着国际上越来越重视从病人的角度对基层照护进行评价,病人就诊体验评价成为国际上评估基层照护质量的一个重要方式,英国的质量＆效果框架(Quality and Outcomes Framework,QOF)中更是赋予病人就诊体验这一指标相当大的权重,用于考核全科医生的绩效。以提高病人就诊体验为目标的基层照护改革无疑将会成为深入贯彻“以病人为中心”理念的突破口。因此,当前有必要从系统、科学的角度对西藏基层照护体系中“病人就诊体验”进行研究,以期为当地后续卫生改革提供研究证据。
研究目的
本研究的总目标是通过制定藏语版的病人就诊体验测量工具,对当地基层照护机构病人就诊体验进行评价,探讨病人就诊体验对健康结果的影响,提出加强西藏自治区基层照护体系能力建设的相关政策建议。具体研究目的包括制定藏语版的病人就诊体验测量工具；评价地区医院、县医院和乡镇卫生院中病人就诊体验,明确哪一级别机构中病人就诊体验最好；评价人民医院和藏医医院中病人就诊体验,明确哪一类别机构中病人就诊体验最好；探讨病人就诊体验与自评健康状况、病人满意度的关系。
研究方法
本研究采用分层立意抽样,根据地理分布和社会经济发展水平,在地区层面抽取日喀则地区和林芝地区；在县层面,日喀则地区抽取拉孜县和江孜县,林芝地区抽取工布江达县,共三个县；在乡镇层面,每个县抽取两个乡镇。样本机构包含2所地区人民医院、2所地区藏医医院、3所县医院、6所乡镇卫生院。由经过培训的当地卫生局调查员,采用基层照护评估工具藏语版对18岁以上门诊病人进行访谈。共调查病人1440人,剔除不合格问卷54份,最终得到有效问卷1386份。其中,地区级医院、县医院、乡镇卫生院分别为692人、336人、358人。样本人群平均年龄为41.72±13.74岁,其中,男性占46.4%,60岁以上老人占11.7%,年平均家庭收入为31400±26482元。采用标准心理计量学方法对基层照护评估工具藏语版信度和效度进行分析；单因素分析中,采用方差分析,对地区医院、县级医院和乡镇卫生院三级机构病人就诊体验进行比较分析；采用t检验,对藏医医院和人民医院病人就诊体验进行比较分析。多因素分析中,在控制人口社会学、卫生服务利用、健康状况因素后,采用多元线性回归,分别分析机构类型对病人就诊体验和各维度的影响；在控制人口社会学、卫生服务利用和健康行为因素后,采用二元Logistic回归模型,分别分析病人就诊体验及各维度对自评健康状况的影响；在控制人口社会学、卫生服务利用和健康状况因素后,采用二元Logistic回归模型,分别分析病人就诊体验及各维度对病人满意度的影响。
主要研究结果
(1)基层照护评估工具藏语版的信度和效度：主成分分析结果显示,PCAT藏语版最终包括7个多条目维度和2个单条目维度,共28个条目,方差贡献率为60.7%。总体克朗巴赫系数为0.92；7个多条目维度中,除就诊等候时间维度外,其余维度克朗巴赫系数均在0.7以上；条目维度相关系数都远远超过0.3的标准；显示PCAT藏语版内部一致性良好。7个多条目维度中,条目维度相关系数、条目维度相关系数极差、条目其他维度相关系数、各维度成功率、各维度内部一致性相关系数都很好地满足量表假设检验的要求。
(2)不同级别机构中病人就诊体验的差异：地区医院、县医院、乡镇卫生院病人中教育程度和年家庭收入差异最为显著；机构级别越低,病人文化程度越低、经济水平越差。乡镇卫生院病人就诊体验总体得分最高(86.64),县医院次之(82.01),地区医院最低(77.42),具体到各个维度,乡镇卫生院尤其是在第一次接触、就诊等候时间、跟踪治疗效果、调查病人需求4个维度得分远高于地区医院和县医院。在控制人口社会学、卫生服务利用、健康状况因素后,三者间的差距基本未有变化。控制因素中,初中以下文化程度、已婚、自评健康的病人对就诊体验评价较高。
(3)不同类别机构中病人就诊体验的差异：相比人民医院,藏医医院中老年人比重较大,初中以下文化程度比重较大,年家庭收入低于30000元的所占比重较大。藏医医院病人就诊体验总体评分(80.00)高于人民医院(74.03)。具体到各个维度,在第一次接触、综合性-医疗服务、综合性-社会服务、与家人沟通、同一位医生、跟踪治疗效果六个维度,藏医医院评分高于人民医院,尤其是在跟踪治疗效果维度,藏医医院评分高出近15分。在控制了人口社会学、卫生服务利用、健康状况因素后,两者之间的差异基本未有变化。控制因素中,自评健康、过去一年就诊次数较少的病人对就诊体验评价较高。
(4)病人就诊体验与自评健康状况的关系：控制人口社会学、卫生服务利用、健康行为因素后,二元Logistic回归模型结果显示,病人就诊体验总体得分OR值为1.023,即病人就诊体验总体得分每增加1分,病人自评为健康的概率提高2.3%。具体到每个维度,第一次接触、综合性-社会服务、跟踪治疗效果三个维度对自评健康状况的影响较大,其中每个维度得分每增加1分,病人自评健康的概率分别提高2.1%、1.8%、1.6%。其他因素中,初中及以上文化程度、已婚、过去一年未住院、每周饮酒3次以下、每周锻炼至少3次的病人自评为健康的概率较高。
(5)病人就诊体验与满意度的关系：控制人口社会学、健康状况因素、卫生服务利用因素后,二元Logistic回归模型结果显示,病人就诊体验总体得分OR值为1.128,即病人就诊体验总体得分每增加1分,病人评价为满意的概率提高12.8%。具体到每个维度,第一次接触、综合性-社会服务、与家人沟通三个维度对病人满意度的影响较大,其中每个维度得分每增加1分,病人满意的概率分别提高7.0%、5.0%、6.2%。其他因素中,初中以下文化程度、已婚、自评为健康、过去一年未住院、过一年就诊次数至少4次的病人评价为满意的概率较高。
结论和政策建议
基层照护是贯彻落实“以病人为中心”、实现全民健康覆盖目标的重要途径。尤其在地广人稀的西藏,基层照护的作用尤为重要。本研究采用藏语版基层照护评估工具对西藏自治区不同级别和不同类别机构所提供基层照护的病人就诊体验进行测量及比较分析,并系统分析了基层照护及各维度对自评健康状况及病人满意度的影响。研究显示,乡镇卫生院所提供基层照护中病人就诊体验最优,就诊人群中教育程度较低、收入水平较低。藏医医院所提供基层照护中病人就诊体验优于人民医院,就诊人群中老年人较多、教育程度较低、收入水平较低。提高基层照护病人的就诊体验,可以显著提高病人的自评健康状况与满意度,各维度中第一次接触维度的影响最为显著。
根据上述结论有以下政策建议：1)增加乡镇卫生院人员数量,进一步完善其基层照护功能。鉴于西藏地理可及性问题,乡镇卫生院卫生人员配置标准应综合考虑服务人口和地理面积。根据当地实际情况,有目的地针对乡镇卫生院现有人员加强培训。2)逐步在乡镇卫生院开设藏医科,配备藏医技术人员。鉴于乡镇卫生院地理可及性的优势,以及农牧区老百姓对藏医药的需求更大,应充分发挥藏医药在基层照护中的作用。3)逐步建立家庭医生责任制度,建立医生与签约病人的长期关系。在乡镇卫生院人员逐步配齐后,转变其服务提供模式,建立家庭医生责任制度。每个乡镇卫生院医生负责辖区几个村子居民的健康问题,在各个村子乡村医生的协助下,根据当地百姓的需求提供服务。4)地区级医院和县级医院可考虑将门诊服务分为全科门诊和专科门诊。全科门诊主要负责首诊病人,专科门诊主要负责各乡镇和各县转诊来的病人,分清各自职责,加强区域内所需的专科能力建设。
Background
With socioeconomic development, health system in Tibet has gained great improvement, including basic infrastructure, and health service delivery network. Medical system in agricultural and pastoral areas has been established, and full-coverage of health insurance has been achieved. Life expectancy has increased from35.5in the initial post-liberation period to current67, maternal mortality rate and infant mortality rate has declined28.6times and20.7times respectively compared with initial post-liberation period. Much international evidence showed that good primary care could contribute to significant population health outcome, and health system in Tibet is a primary care based system. Therefore, the great health outcome achievement in Tibet should result from the primary care based health system building.
In Tibet, most of prefecture level hospitals are first level or second level hospitals, nearly half of county hospitals are first level hospitals, and the other half never receive national hospital classification standard evaluation. One of main functions of prefecture and county hospitals is to provide primary care to local residents. Tibet has a vast territory, geographical accessibility hinders patients' choice, and grading diagnosis and treatment system has not been established, so patients regularly choose the nearest facility when they have primary care demand. Traditional Tibetanmedicine is very popular among local residents, therefore Tibetan resident usually go to Tibetan medicine facility when they need primary care. As a result, prefecture hospitals, county hospitals, Tibetan medicine hospitals are also main primary care provider in Tibet. The estimated outpatient numbers based on internal materials in prefecture hospital, county hospitals, township health center, Tibetan medicine hospitals are900thousands、2400thousands、3400thousands,900thousands respectively.
To achieve the aim of "patient-centered care", inland and Tibet pay more attention to patient demand to reform the health service delivery model through "bottom to up" approach. Without doubt, primary care system capacity building will be one important reform aim. Primary care is patient-centred care, and patient experience is one significant indicator to measure patient-centred care, which is also one of quality indicator proposed by Institute of Medicine (IOM). Following more and more emphasis on primary care assessment form patients'perspective, patient experience assessment becomes one important approach to measure primary care quality. In UK, Quality and Outcomes Framework (QOF) gives more weight to patient experience assessment result to evaluate GP's performance. Patient experience improvement based primary care reform may be one efficient approach to achieve patient-centered care. Therefore, it is necessary to study patient experience of primary care in Tibetan area to provide technical support for government.
Objective
The overall objective is to adapt Primary Care Assessment Tool-Chinese version into Tibetan-version, through which to measure primary care quality among different health care settings, explore the association between primary care quality and health outcome, and provide policy recommendations for improving Tibet primary care system capacity building. The specific targets include:adapt Primary Care Assessment Tool-Chinese version into Tibetan version; measure primary care quality among prefecture hospitals, county hospitals, and township health centers; measure primary care quality among western medicine hospitals and Tibetan medicine hospitals; explore the association between primary care quality and self-rated health, patient satisfaction.
Methods
A stratified, purposive sampling approach was used to select study sites. Socioeconomic and geographic situation were the two main factors employed to determine the selection to ensure our sampling sites represented Tibetan health agencies at each level.Giventhe socioeconomic level and geographic location of TAR's seven prefectures, two prefectures were sampled:Shigatse, located in western Tibet with18low socioeconomic level counties, and Linzhi in eastern Tibet withseven high socioeconomic level counties.
In Shigatse prefecture, we selected:a prefecture people's hospital and a prefecture Tibetan medicine hospital; at the county level, the Jiangzi and Lazi hospitals; and two health centers per sampling county at the township level. In Linzhi prefecture, we selected:a prefecture people's hospital and a prefecture Tibetan medicine hospital; the Gongbujiangda county hospital; and two township health centers in Gongbujiangda county. The sample sizes were comparable to three key studies (Shi2001, Samuel YS Wong2010, Harry H.X.Wang2013) that showed300interviews were required at each sample site level for comparison analysis. Considering some collected questionnaires may contain missing data,10additional questionnaires were conducted at each township health center,20additional questionnaires at each county hospital and30additional questionnaires at each prefecture people's hospital and prefecture Tibetan medicine hospital.Overall, two prefecture people's hospitals (360interviews), two prefecture Tibetan medicine hospitals (360interviews), three county hospitals (360interviews) and six township health centers (360interviews)yielded1440interviews.
The data were collected between September and October2013by trained interviewers from the local health bureau through face-to-face interviews with patients18years or older,who had completed their visits to township health centers or hospital outpatients. Patients were given small gifts (worth10RMB) of appreciation upon completion of the interview. While1440questionnaires were administered,54questionnaires were deleted due to missing data, leaving1386completed questionnaires. Among the sample patients, the average age is41.72, almost half are male, more than10%are old people (>60), the average annual household income is31400RMB. Standard psychometrics method was used to conduct analysis of validity and reliability; analysis of variance was used to compare primary care quality among prefecture hospital, county hospital, and township health center; t test was used to compare primary care quality between western medicine hospital and Tibetan medicine hospital; multi-variate linear regression analysis was used to explore the association between facility type and primary care quality after controlling socioeconomic factors, health service utilization factors, health status; binary Logistic regression analysis was used to explore the association between primary care quality and self-rated health status after controlling socioeconomic factors, health service utilization factors, health behaviours; binary Logistic regression analysis was used to explore the association between primary care quality and patient satisfaction after controlling socioeconomic factors, health service utilization factors, health status.
Main Results
(1)The validity and reliability of Primary Care Assessment Tool-Tibetan Version (PCAT-T):principal component analysis result showed PCAT-T included seven multi-item scales and two single-item scales, totally28items, the extracted factors could explain60.7%of the common variance. The total Cronbach's coefficient was0.92, all Cronbach's coefficients of multi-item scales was above0.7except waiting time scale; all item-total correlations were above0.3; which revealed that PCAT-T achieved good internal consistency. Item-scale correlation, item-other scale correlation, range of item-scale correlations, scaling success rate, Intraclass Correlation were all very satisfied with the scaling assumptions.
(2)Patient experience of primary care among prefecture hospital, county hospital, township health center:patients among different facilities have significant difference of education level and economic level; the higher the facility, the higher patients' education level and economic level. Township health center achieved the highest PCAT score especially on the scales of first contact, waiting time, follow up and patient demand survey, while PCAT score of prefecture hospital was the lowest. There is no significant change of PCAT score among different facilities after controlling socioeconomic factors, health utilization factors and health status. About other factors, patients with lower education level, married and good self-rated health status had higher PC AT scores.
(3) Patient experience of primary care between western medicine hospital and Tibetan medicine hospital:patients in Tibetan medicine hospitals had lower education level and economic level, and more old people. Tibetan medicine hospital achieved higher PCAT score especially on the follow up scale. There is no significant change of PCAT score after controlling socioeconomic factors, health utilization factors and health status. About other factors, patients with good self-rated health status, less frequent visits had higher PCAT scores.
(4) Association between patient experience and self-rated health status:After controlling socioeconomic factors, health utilization factors and healthbehavior factors, the result of binary Logistic regression model showed the OR of PCAT total score was1.023, which meant when PCAT score increased1point, the possibility of good self-rated health increased2.3%; about each scales, the ORs of first contact, comprehensiveness-social care, and follow up were1.021,1.018,1.016. Patients with lower education level, married, no inpatient experience during the past year, less frequent drinking, more frequent exercise had the higher probability of good self-rated health.
(5) Association between patient experience and patient satisfaction:After controlling socioeconomic factors, health utilization factors and health status, the result of binary Logistic regression model showed the OR of PCAT total score was1.128, which meant when PCAT score increased1point, the possibility of patient satisfaction increased12.8%; about each scales, the ORs of first contact, comprehensiveness-social care, and communication with family were1.070,1.050,1.062. Patients with lower education level, married, good self-rated health, no inpatient experience during the past year, more frequent visits had the higher probability of good self-rated health.
Conclusions and Policy recommendations
Primary care is a main approach to achieve the aim of patient-centered care and universial health coverage, especially in Tibet. Through our study, we found that township health center patients had the best patient experience of primary care, compared with prefecture hospitals and county hospitals; Tibetan medicine hospital patients had better patient experience of primary care compared with western medicine hospital; the main characteristics of patients in township health centers and Tibetan medicine hospitals were lower education level and economic level. Patient experience had positive association with self-rated health and patient satisfaction, especially the first contact scale in primary care setting.
Policy recommendations:1) Increase the number of health staff in township health center to improve its primary care function. Both of population and geography factors should be considered when allocate health staff in township health centers; demand-based training should be conducted to health staff in townshiphealth centers.2) Establish Tibetan medicine department in township health centers. Tibetan medicine service should be expanded in primary care.3) Establish family doctor responsible system. Each health staff in the township health center should be responsible for several village residents'health under the assistance of village doctor, so as to establish the sustainable relationship with local residents.4) Outpatient departments in prefecture and county hospitals should be separated into primary care department and specialty department. Primary care department should be responsible for first contact patents, while specialty department should be responsible for referred patients.
随着经济社会全面发展,西藏的医疗卫生事业也取得重大成就,卫生基础设施不断完善,以拉萨为中心辐射全区城乡的医疗卫生服务网基本形成。农牧区医疗制度全面建立,实现医疗制度全覆盖,人均期望寿命从和平解放初期的35.5岁提高到现在的67岁,孕产妇和婴儿死亡率分别比和平解放前下降28.6倍和20.7倍。国际上大量研究证明良好的基层照护(Primary Care)可显著提高人群健康状况,西藏的卫生体系也是以基层照护为基础。因此,西藏健康状况的巨大改善应该源自于其以基层照护为重点的卫生体系建设。
在西藏,绝大多数地区级医院为二级医院或一级医院,县级医院中一半左右为一级医院、一半左右未评级,地区级和县级医院功能不完善,主要为当地居民提供常见病、多发病的诊疗工作,兼顾预防、保健、康复功能。西藏幅员辽阔,地理可及性严重影响了病人的就诊选择,加之西藏未建立分级诊疗制度,因此,当居民产生基层照护需求时,往往选择最近的医疗机构就诊。因此,地区级医院和县级医院也是西藏重要的基层照护提供者。此外,传统的藏医药也深受广大藏区群众信赖,藏医医疗机构也是广大藏区群众就诊的首选,因此各级藏医医疗机构也成为西藏基层照护的一个主要提供者。根据相关资料估计,2012年地区级医院、县级医院、乡镇卫生院诊疗人次数分别为90万、240万、340万,藏医医疗机构就诊人次数达到90万。
随着“以病人为中心”理念的在我国的逐步深入,我国也越来越重视根据病人需求,“采用自下而上”的方式改革其卫生服务提供模式,加强基层照护体系建设无疑将会成为改革的一个目标。基层照护是以“病人为中心’(Patient-Centred Care)的照护服务,病人就诊体验(Patient Experience)是测量“以病人为中心”的一个重要指标,也是美国医学研究所建议的卫生服务质量的一个目标,主要应用于基层照护机构中(Primary Care Settings)。随着国际上越来越重视从病人的角度对基层照护进行评价,病人就诊体验评价成为国际上评估基层照护质量的一个重要方式,英国的质量＆效果框架(Quality and Outcomes Framework,QOF)中更是赋予病人就诊体验这一指标相当大的权重,用于考核全科医生的绩效。以提高病人就诊体验为目标的基层照护改革无疑将会成为深入贯彻“以病人为中心”理念的突破口。因此,当前有必要从系统、科学的角度对西藏基层照护体系中“病人就诊体验”进行研究,以期为当地后续卫生改革提供研究证据。
研究目的
本研究的总目标是通过制定藏语版的病人就诊体验测量工具,对当地基层照护机构病人就诊体验进行评价,探讨病人就诊体验对健康结果的影响,提出加强西藏自治区基层照护体系能力建设的相关政策建议。具体研究目的包括制定藏语版的病人就诊体验测量工具；评价地区医院、县医院和乡镇卫生院中病人就诊体验,明确哪一级别机构中病人就诊体验最好；评价人民医院和藏医医院中病人就诊体验,明确哪一类别机构中病人就诊体验最好；探讨病人就诊体验与自评健康状况、病人满意度的关系。
研究方法
本研究采用分层立意抽样,根据地理分布和社会经济发展水平,在地区层面抽取日喀则地区和林芝地区；在县层面,日喀则地区抽取拉孜县和江孜县,林芝地区抽取工布江达县,共三个县；在乡镇层面,每个县抽取两个乡镇。样本机构包含2所地区人民医院、2所地区藏医医院、3所县医院、6所乡镇卫生院。由经过培训的当地卫生局调查员,采用基层照护评估工具藏语版对18岁以上门诊病人进行访谈。共调查病人1440人,剔除不合格问卷54份,最终得到有效问卷1386份。其中,地区级医院、县医院、乡镇卫生院分别为692人、336人、358人。样本人群平均年龄为41.72±13.74岁,其中,男性占46.4%,60岁以上老人占11.7%,年平均家庭收入为31400±26482元。采用标准心理计量学方法对基层照护评估工具藏语版信度和效度进行分析；单因素分析中,采用方差分析,对地区医院、县级医院和乡镇卫生院三级机构病人就诊体验进行比较分析；采用t检验,对藏医医院和人民医院病人就诊体验进行比较分析。多因素分析中,在控制人口社会学、卫生服务利用、健康状况因素后,采用多元线性回归,分别分析机构类型对病人就诊体验和各维度的影响；在控制人口社会学、卫生服务利用和健康行为因素后,采用二元Logistic回归模型,分别分析病人就诊体验及各维度对自评健康状况的影响；在控制人口社会学、卫生服务利用和健康状况因素后,采用二元Logistic回归模型,分别分析病人就诊体验及各维度对病人满意度的影响。
主要研究结果
(1)基层照护评估工具藏语版的信度和效度：主成分分析结果显示,PCAT藏语版最终包括7个多条目维度和2个单条目维度,共28个条目,方差贡献率为60.7%。总体克朗巴赫系数为0.92；7个多条目维度中,除就诊等候时间维度外,其余维度克朗巴赫系数均在0.7以上；条目维度相关系数都远远超过0.3的标准；显示PCAT藏语版内部一致性良好。7个多条目维度中,条目维度相关系数、条目维度相关系数极差、条目其他维度相关系数、各维度成功率、各维度内部一致性相关系数都很好地满足量表假设检验的要求。
(2)不同级别机构中病人就诊体验的差异：地区医院、县医院、乡镇卫生院病人中教育程度和年家庭收入差异最为显著；机构级别越低,病人文化程度越低、经济水平越差。乡镇卫生院病人就诊体验总体得分最高(86.64),县医院次之(82.01),地区医院最低(77.42),具体到各个维度,乡镇卫生院尤其是在第一次接触、就诊等候时间、跟踪治疗效果、调查病人需求4个维度得分远高于地区医院和县医院。在控制人口社会学、卫生服务利用、健康状况因素后,三者间的差距基本未有变化。控制因素中,初中以下文化程度、已婚、自评健康的病人对就诊体验评价较高。
(3)不同类别机构中病人就诊体验的差异：相比人民医院,藏医医院中老年人比重较大,初中以下文化程度比重较大,年家庭收入低于30000元的所占比重较大。藏医医院病人就诊体验总体评分(80.00)高于人民医院(74.03)。具体到各个维度,在第一次接触、综合性-医疗服务、综合性-社会服务、与家人沟通、同一位医生、跟踪治疗效果六个维度,藏医医院评分高于人民医院,尤其是在跟踪治疗效果维度,藏医医院评分高出近15分。在控制了人口社会学、卫生服务利用、健康状况因素后,两者之间的差异基本未有变化。控制因素中,自评健康、过去一年就诊次数较少的病人对就诊体验评价较高。
(4)病人就诊体验与自评健康状况的关系：控制人口社会学、卫生服务利用、健康行为因素后,二元Logistic回归模型结果显示,病人就诊体验总体得分OR值为1.023,即病人就诊体验总体得分每增加1分,病人自评为健康的概率提高2.3%。具体到每个维度,第一次接触、综合性-社会服务、跟踪治疗效果三个维度对自评健康状况的影响较大,其中每个维度得分每增加1分,病人自评健康的概率分别提高2.1%、1.8%、1.6%。其他因素中,初中及以上文化程度、已婚、过去一年未住院、每周饮酒3次以下、每周锻炼至少3次的病人自评为健康的概率较高。
(5)病人就诊体验与满意度的关系：控制人口社会学、健康状况因素、卫生服务利用因素后,二元Logistic回归模型结果显示,病人就诊体验总体得分OR值为1.128,即病人就诊体验总体得分每增加1分,病人评价为满意的概率提高12.8%。具体到每个维度,第一次接触、综合性-社会服务、与家人沟通三个维度对病人满意度的影响较大,其中每个维度得分每增加1分,病人满意的概率分别提高7.0%、5.0%、6.2%。其他因素中,初中以下文化程度、已婚、自评为健康、过去一年未住院、过一年就诊次数至少4次的病人评价为满意的概率较高。
结论和政策建议
基层照护是贯彻落实“以病人为中心”、实现全民健康覆盖目标的重要途径。尤其在地广人稀的西藏,基层照护的作用尤为重要。本研究采用藏语版基层照护评估工具对西藏自治区不同级别和不同类别机构所提供基层照护的病人就诊体验进行测量及比较分析,并系统分析了基层照护及各维度对自评健康状况及病人满意度的影响。研究显示,乡镇卫生院所提供基层照护中病人就诊体验最优,就诊人群中教育程度较低、收入水平较低。藏医医院所提供基层照护中病人就诊体验优于人民医院,就诊人群中老年人较多、教育程度较低、收入水平较低。提高基层照护病人的就诊体验,可以显著提高病人的自评健康状况与满意度,各维度中第一次接触维度的影响最为显著。
根据上述结论有以下政策建议：1)增加乡镇卫生院人员数量,进一步完善其基层照护功能。鉴于西藏地理可及性问题,乡镇卫生院卫生人员配置标准应综合考虑服务人口和地理面积。根据当地实际情况,有目的地针对乡镇卫生院现有人员加强培训。2)逐步在乡镇卫生院开设藏医科,配备藏医技术人员。鉴于乡镇卫生院地理可及性的优势,以及农牧区老百姓对藏医药的需求更大,应充分发挥藏医药在基层照护中的作用。3)逐步建立家庭医生责任制度,建立医生与签约病人的长期关系。在乡镇卫生院人员逐步配齐后,转变其服务提供模式,建立家庭医生责任制度。每个乡镇卫生院医生负责辖区几个村子居民的健康问题,在各个村子乡村医生的协助下,根据当地百姓的需求提供服务。4)地区级医院和县级医院可考虑将门诊服务分为全科门诊和专科门诊。全科门诊主要负责首诊病人,专科门诊主要负责各乡镇和各县转诊来的病人,分清各自职责,加强区域内所需的专科能力建设。
Background
With socioeconomic development, health system in Tibet has gained great improvement, including basic infrastructure, and health service delivery network. Medical system in agricultural and pastoral areas has been established, and full-coverage of health insurance has been achieved. Life expectancy has increased from35.5in the initial post-liberation period to current67, maternal mortality rate and infant mortality rate has declined28.6times and20.7times respectively compared with initial post-liberation period. Much international evidence showed that good primary care could contribute to significant population health outcome, and health system in Tibet is a primary care based system. Therefore, the great health outcome achievement in Tibet should result from the primary care based health system building.
In Tibet, most of prefecture level hospitals are first level or second level hospitals, nearly half of county hospitals are first level hospitals, and the other half never receive national hospital classification standard evaluation. One of main functions of prefecture and county hospitals is to provide primary care to local residents. Tibet has a vast territory, geographical accessibility hinders patients' choice, and grading diagnosis and treatment system has not been established, so patients regularly choose the nearest facility when they have primary care demand. Traditional Tibetanmedicine is very popular among local residents, therefore Tibetan resident usually go to Tibetan medicine facility when they need primary care. As a result, prefecture hospitals, county hospitals, Tibetan medicine hospitals are also main primary care provider in Tibet. The estimated outpatient numbers based on internal materials in prefecture hospital, county hospitals, township health center, Tibetan medicine hospitals are900thousands、2400thousands、3400thousands,900thousands respectively.
To achieve the aim of "patient-centered care", inland and Tibet pay more attention to patient demand to reform the health service delivery model through "bottom to up" approach. Without doubt, primary care system capacity building will be one important reform aim. Primary care is patient-centred care, and patient experience is one significant indicator to measure patient-centred care, which is also one of quality indicator proposed by Institute of Medicine (IOM). Following more and more emphasis on primary care assessment form patients'perspective, patient experience assessment becomes one important approach to measure primary care quality. In UK, Quality and Outcomes Framework (QOF) gives more weight to patient experience assessment result to evaluate GP's performance. Patient experience improvement based primary care reform may be one efficient approach to achieve patient-centered care. Therefore, it is necessary to study patient experience of primary care in Tibetan area to provide technical support for government.
Objective
The overall objective is to adapt Primary Care Assessment Tool-Chinese version into Tibetan-version, through which to measure primary care quality among different health care settings, explore the association between primary care quality and health outcome, and provide policy recommendations for improving Tibet primary care system capacity building. The specific targets include:adapt Primary Care Assessment Tool-Chinese version into Tibetan version; measure primary care quality among prefecture hospitals, county hospitals, and township health centers; measure primary care quality among western medicine hospitals and Tibetan medicine hospitals; explore the association between primary care quality and self-rated health, patient satisfaction.
Methods
A stratified, purposive sampling approach was used to select study sites. Socioeconomic and geographic situation were the two main factors employed to determine the selection to ensure our sampling sites represented Tibetan health agencies at each level.Giventhe socioeconomic level and geographic location of TAR's seven prefectures, two prefectures were sampled:Shigatse, located in western Tibet with18low socioeconomic level counties, and Linzhi in eastern Tibet withseven high socioeconomic level counties.
In Shigatse prefecture, we selected:a prefecture people's hospital and a prefecture Tibetan medicine hospital; at the county level, the Jiangzi and Lazi hospitals; and two health centers per sampling county at the township level. In Linzhi prefecture, we selected:a prefecture people's hospital and a prefecture Tibetan medicine hospital; the Gongbujiangda county hospital; and two township health centers in Gongbujiangda county. The sample sizes were comparable to three key studies (Shi2001, Samuel YS Wong2010, Harry H.X.Wang2013) that showed300interviews were required at each sample site level for comparison analysis. Considering some collected questionnaires may contain missing data,10additional questionnaires were conducted at each township health center,20additional questionnaires at each county hospital and30additional questionnaires at each prefecture people's hospital and prefecture Tibetan medicine hospital.Overall, two prefecture people's hospitals (360interviews), two prefecture Tibetan medicine hospitals (360interviews), three county hospitals (360interviews) and six township health centers (360interviews)yielded1440interviews.
The data were collected between September and October2013by trained interviewers from the local health bureau through face-to-face interviews with patients18years or older,who had completed their visits to township health centers or hospital outpatients. Patients were given small gifts (worth10RMB) of appreciation upon completion of the interview. While1440questionnaires were administered,54questionnaires were deleted due to missing data, leaving1386completed questionnaires. Among the sample patients, the average age is41.72, almost half are male, more than10%are old people (>60), the average annual household income is31400RMB. Standard psychometrics method was used to conduct analysis of validity and reliability; analysis of variance was used to compare primary care quality among prefecture hospital, county hospital, and township health center; t test was used to compare primary care quality between western medicine hospital and Tibetan medicine hospital; multi-variate linear regression analysis was used to explore the association between facility type and primary care quality after controlling socioeconomic factors, health service utilization factors, health status; binary Logistic regression analysis was used to explore the association between primary care quality and self-rated health status after controlling socioeconomic factors, health service utilization factors, health behaviours; binary Logistic regression analysis was used to explore the association between primary care quality and patient satisfaction after controlling socioeconomic factors, health service utilization factors, health status.
Main Results
(1)The validity and reliability of Primary Care Assessment Tool-Tibetan Version (PCAT-T):principal component analysis result showed PCAT-T included seven multi-item scales and two single-item scales, totally28items, the extracted factors could explain60.7%of the common variance. The total Cronbach's coefficient was0.92, all Cronbach's coefficients of multi-item scales was above0.7except waiting time scale; all item-total correlations were above0.3; which revealed that PCAT-T achieved good internal consistency. Item-scale correlation, item-other scale correlation, range of item-scale correlations, scaling success rate, Intraclass Correlation were all very satisfied with the scaling assumptions.
(2)Patient experience of primary care among prefecture hospital, county hospital, township health center:patients among different facilities have significant difference of education level and economic level; the higher the facility, the higher patients' education level and economic level. Township health center achieved the highest PCAT score especially on the scales of first contact, waiting time, follow up and patient demand survey, while PCAT score of prefecture hospital was the lowest. There is no significant change of PCAT score among different facilities after controlling socioeconomic factors, health utilization factors and health status. About other factors, patients with lower education level, married and good self-rated health status had higher PC AT scores.
(3) Patient experience of primary care between western medicine hospital and Tibetan medicine hospital:patients in Tibetan medicine hospitals had lower education level and economic level, and more old people. Tibetan medicine hospital achieved higher PCAT score especially on the follow up scale. There is no significant change of PCAT score after controlling socioeconomic factors, health utilization factors and health status. About other factors, patients with good self-rated health status, less frequent visits had higher PCAT scores.
(4) Association between patient experience and self-rated health status:After controlling socioeconomic factors, health utilization factors and healthbehavior factors, the result of binary Logistic regression model showed the OR of PCAT total score was1.023, which meant when PCAT score increased1point, the possibility of good self-rated health increased2.3%; about each scales, the ORs of first contact, comprehensiveness-social care, and follow up were1.021,1.018,1.016. Patients with lower education level, married, no inpatient experience during the past year, less frequent drinking, more frequent exercise had the higher probability of good self-rated health.
(5) Association between patient experience and patient satisfaction:After controlling socioeconomic factors, health utilization factors and health status, the result of binary Logistic regression model showed the OR of PCAT total score was1.128, which meant when PCAT score increased1point, the possibility of patient satisfaction increased12.8%; about each scales, the ORs of first contact, comprehensiveness-social care, and communication with family were1.070,1.050,1.062. Patients with lower education level, married, good self-rated health, no inpatient experience during the past year, more frequent visits had the higher probability of good self-rated health.
Conclusions and Policy recommendations
Primary care is a main approach to achieve the aim of patient-centered care and universial health coverage, especially in Tibet. Through our study, we found that township health center patients had the best patient experience of primary care, compared with prefecture hospitals and county hospitals; Tibetan medicine hospital patients had better patient experience of primary care compared with western medicine hospital; the main characteristics of patients in township health centers and Tibetan medicine hospitals were lower education level and economic level. Patient experience had positive association with self-rated health and patient satisfaction, especially the first contact scale in primary care setting.
Policy recommendations:1) Increase the number of health staff in township health center to improve its primary care function. Both of population and geography factors should be considered when allocate health staff in township health centers; demand-based training should be conducted to health staff in townshiphealth centers.2) Establish Tibetan medicine department in township health centers. Tibetan medicine service should be expanded in primary care.3) Establish family doctor responsible system. Each health staff in the township health center should be responsible for several village residents'health under the assistance of village doctor, so as to establish the sustainable relationship with local residents.4) Outpatient departments in prefecture and county hospitals should be separated into primary care department and specialty department. Primary care department should be responsible for first contact patents, while specialty department should be responsible for referred patients.
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[52]Kim TW, S.J., Cheng DM, etal. Primary care quality and addiction severity:a prospective cohort study. Health Serv Res,2007.2(2):755-72.
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[12]Dagdeviren N, A.Z. An evaluation of patient satisfaction in Turkey with the EUROPEP instrument. Yonsei Med J,2004.45(1):23-8.
[13]Lionis C, T.M., Bardis V,etal. Seeking quality improvement in primary care in Crete, Greece: the first actions. Croat Med J.2004.45(5):599-603.
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[15]Esch BM, M.F., Busato A, etal.Patient satisfaction with primary care:an observational study comparing anthroposophic and conventional care. Health Qual Life Outcomes.2008.30;6:74.
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[21]Harry H.X.Wang, S.W., MartinC.S, etal.Patients'experiences in different models of community health centers in southern China. Annal of Family Medicine.2013.11(6):517-526.
[22]WongSYS, K.K., Griffiths SM,etal.Comparison of primary care experiences among adults in general outpatient clinics and private general practice clinics in HongKong. BMC Public Health, 2010.10:397.
[23]Kontopantelis E, R.M., Reeves D. Patient experience of access to primary care:identification of predictors in a national patient survey. BMC Fam Pract,2010.28(11):61.
[24]Murray A, S.D., Rogers WH, etal.Part-time physicians. Physician workload and patient-based assessments of primary care performance. Arch Fam Med,2000.9(4):327-32.
[25]Wensing M, V.P., Kersnik J, etal.Patient satisfaction with availability of general practice:an international comparison. Int J Qual Health Care.2002.14(2):111-8.
[26]Heje HN, V.P., Sokolowski I, etal.Patient characteristics associated with differences in patients' evaluation of their general practitioner. BMC Health Serv Res.2008.20;8:178.
[27]Wensing M, H.J., Grol R, etal.Patient evaluations of accessibility and co-ordination in general practice in Europe. Health Expect.2008. 11(4):384-90.
[28]Shi, L.The relationship between primary care and life chances. Journal of Health Care for the Poor and Underserved,1992.3:321-35.
[29]Shi, L.Primary care, speciality care, and life chances. Journal of Health Services,1994.24: 431-458.
[30]Vogel, R.L., R.J.Ackermann. Is primary care physicians supply correlated with health outcomes. Internation Journal of Health Service,1998.28:183-196.
[31]Shi, L., B. Starfield.Primary care, income inequality, and self-rated health in the United States: a mix-level analysis. Internation Journal of Health Service,2000.30:541-555.
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[34]Gulliford, M.C., R.H.Jack, G.Adams, etal. Availability and structure of primray medical care services and population health and health care indicators in England. BMC Health Service Research,2004.4:12.
[35]Sarma S, P.C.The relationship between family physician density and health related outcomes: the Canadian evidence. Cah Sociol Demogr Med.2008.48(1):61-105.
[36]Lee J, P.S., Choi K,etal. The association between the supply of primary care physicians and population health outcomes in Korea. Fam Med.2010.42(9):628-35.
[37]Roos, N.P.Who should do the surgery? Tonsillectomy-adenoidectomy in one Canada province. Inquiry,1979.16:73-83.
[38]Franks, P., K.Fiscella.Primary care physicians, specialists as personal physicians, health care expenditures and mortality experience. Journal of Family Practice,1998.47:105-109.
[39]Villalbi, J.R., A.Guarga,M.I.Pasarin, etal.An evaluation of the impact of primary care reform on health. Atencion Primaria,1999.24:468-474.
[40]Regan, J., A.H.Schempf,J.Yoon, etal.The role of federally funded health centers in serving the rural population. Journal of Rural Health,2003.19:117-124.
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[42]Starfield, B.Primary care and health. A cross-national comparison. Journal of the American Medical Association,1991.266:2268-2271.
[43]Flocke, S.A., K.C.Stange,S.J.Zyzanski.The association of attributes of primary care with the delivery of clinical preventive services. Medical Care,1998.36:21-30.
[44]Ryan, S., A.Riley, M.Kang, etal.The effects of regular source of care and health need on medical care use among rural adolescents. Archives of Pediatric and Adolesent Medicine, 2001.155:184-190.
[45]Shi, L., B. Starfield.,R.Politzer, etal.Primary care, self-rated health, and reductions in social disparities in health. Health Service Research,2002.37:529-550.
[46]Starfield, B.S., L..Policy relevant determinants of health:an international perspective. Health Policy,2002.60:201-218.
[47]Macinko, J.B.S., L.Shi..The contribution of primary care system to health outcomes within Organization for Economic Cooperation and Development (OECD)countries,1970-1998. Health Service Research,2003.38:831-865.
[48]Saultz JW, L.J.. Interpersonal continuity of care and care outcomes:a critical review. Ann Fam Med.2005.3(2):159-66.
[49]Dreiher J, C.D., Rosenbluth Y,etal.The association between continuity of care in the community and health outcomes:a population-based study. Isr J Health Policy Res.2012. 1(1):21.
[50]Nak JS, J.F., Ki Heum P,etal. Higher quality primary care is associated with good self-rated health status. Family Practice,2013.30:568-575.
[51]Dana Gelb Safran, D.A.T., William H. Rogers, etal. Linking primary care performance to outcomes of care. The Journal of family practice 47(3):213-20.,1998.
[52]Kim TW, S.J., Cheng DM, etal. Primary care quality and addiction severity:a prospective cohort study. Health Serv Res,2007.2(2):755-72.
[53]Per Hjortdahl, E.L Continuity of care in general practice:effect on patient satisfaction. BMJ Open,1992.304(6837):1287-1290.
[54]Cabana MD, J.S.Does continuity of care improve patient outcomes? J Fam Pract.2004. 53(12):974-80.
[55]Fan VS, B.M., McDonell MB, etal. Continuity of care and other determinants of patient satisfaction with primary care. J Gen Intern Med.2005.20(3):226-33.
[56]Mireia S C, E.P.R., Joan G B,etal.Family medicine attributes related to satisfaction, health and costs. Family Practice.2006.23 (3):308-316.
[57]Rocha KB, R.-S.M., Pasarin Ml,etal. Assessment of primary care in health surveys:a population perspective. Eur J Public Health.2012.22(1):14-9.
[58]Lee, P.The Problem:Assessing the Primary Care Paradigm. In Proceedings:Volume I. The National Primary Care Conference. Washington, D.C,1992. March 29-31.
[59]Fry, J. Primary Care. London:Heineman,1980.
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[61]Starfield, B.Primary Care:Concept, Evaluation, and Policy. New York:Oxford University Press, 1992
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[64]Millis, J.S.The Graduate Education of Physicians.Report of the Citizens'Commission on Graduate Medical Education. Chicago:American Medical Association,1966.
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[66]IOM., Primary Care:America's Health in a New Era.1996.
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[72]路冠军.均等化取向下的农村公共卫生服务体系构建.农村经济,2007(11)：83-85.
[73]孙逊,张寓景,汤明新,等.基本卫生服务均等化界定、评价及衡量方法[J].卫生软科学,2009,23(4)：425-426.
[74]梁万年.全科医学、全科医疗和全科医生.中国学校卫生.2004,25(2)：252-256.
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