Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Shanghai Sixth People's Hospital East Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai, China.
Inquiry. 2021 Jan-Dec;58:469580211009667. doi: 10.1177/00469580211009667.
Studies globally have provided substantial evidence that PHC could conduct doctor-visiting behaviors, control medical expense, and improve population health. This study aimed to map how family doctor (FD) in Shanghai achieved gate-keeper goals including health management, medical expense control, and conducting ordered doctor-visiting behavior. A total of 2754 and 1995 valid questionnaires were collected in 2013 and 2016 respectively in Shanghai. The data were analyzed using structural equation modeling (SEM). Invariance analysis was also performed for 2 waves of data. We found that the coefficient of cognition on health management (β = 0.26, < .05) was larger than that of signing with FD (β = 0.06, < .05). SEM model also showed that first-contact at community health service center (CHSC) had a positive effect on health management (β = 0.30, < .05), and the latter also affected health management results positively (β = 0.39, < .05), suggesting that the path for FD was through first-contact and health management. Besides, the gate-keeper role of medical expense control was significant through the first-contact (β = -0.12, < .05) mediation rather than health management (β = 0.03, > .05). The model fit was acceptable (RMSEA = 0.033). A "cognition-behavior-outcomes (health and medical expense)" path of FD's gate-keeper role was found. It is necessary to consolidate FD contracted services rather than reimbursement discount the latter of which is proved to be unsustainable.
研究表明，初级卫生保健（PHC）可以改善人口健康，控制医疗费用并规范就医行为。本研究旨在绘制上海家庭医生（FD）如何实现守门人目标，包括健康管理、控制医疗费用和规范就医行为。2013 年和 2016 年分别收集了 2754 份和 1995 份有效问卷。使用结构方程模型（SEM）分析数据。还对 2 波数据进行了不变性分析。我们发现，认知对健康管理的系数（β=0.26，<0.05）大于与 FD 签约的系数（β=0.06，<0.05）。SEM 模型还显示，社区卫生服务中心（CHSC）的首诊对健康管理有积极影响（β=0.30，<0.05），而后者也对健康管理结果有积极影响（β=0.39，<0.05），这表明 FD 的路径是通过首诊和健康管理。此外，通过首诊（β=-0.12，<0.05）而不是健康管理（β=0.03，>0.05）来实现医疗费用控制的守门人角色。模型拟合度可接受（RMSEA=0.033）。发现了 FD 守门人角色的“认知-行为-结果（健康和医疗费用）”路径。有必要巩固 FD 签约服务，而不是实施被证明不可持续的报销折扣。
