中国分级医疗体系改革最早试点的纵向研究：新型慢性病管理是否有效？

Longitudinal study of the earliest pilot of tiered healthcare system reforms in China: Will the new type of chronic disease management be effective?

机构信息

School of Public Administration and Policy, Renmin University of China, 59 Zhongguancun Street, Beijing, 100872, China.

出版信息

Soc Sci Med. 2021 Sep;285:114284. doi: 10.1016/j.socscimed.2021.114284. Epub 2021 Jul 31.

DOI:10.1016/j.socscimed.2021.114284

PMID:34388618

Abstract

BACKGROUND

In 2016, the tiered healthcare model featuring "specialists + general practitioners + health managers" in Xiamen was recognized by the Medical Reform Office of State Council and was promoted as a model to replace hospital-centric care with community-based care. This study evaluated the impact of the Xiamen's tiered healthcare system reform on health outcomes and healthcare spending among chronic disease patients.

METHODS

Data were derived from Xiamen's electronic health record (EHR) and medical claims systems. The sample included 154,651 individuals with hypertension and 50,722 individuals with diabetes from Xiamen between 2012 and 2016. The dependent variables included rates of disease under control and total treatment costs. Patients were grouped by the types of chronic disease management: precision management, regular management, or without management. Kaplan-Meier, Cox survival analysis and PSM + DID method (Propensity score matching and difference-in-difference method) were used to compare the management outcomes by group.

FINDINGS

The precision management group showed better clinical quality performance than the regular management group. Under-control disease rates in the precision management group showed a continuous improvement trend, while the regular management group showed a ceiling effect after ten months. Under-control rates in the precision management group increased over 40% for hypertension and over 30% for diabetes, higher than that increases found in the regular management group. Reform was also associated with consistent reductions in annual per capita total treatment costs across groups. The cost-savings in the precision management group between 2014 and 2016 was 381 Chinese yuan (CNY) for hypertension and 1117 CNY for diabetes, compared with the group without management.

INTERPRETATION

The results in this study demonstrated the associations between tiered healthcare system reform and better clinical quality performance and improved treatment cost-saving. Developing methods to promote the policy and increase implementation are also important aspects of healthcare reform.

摘要

背景

2016 年，厦门市推行的“专科医生+全科医生+健康管理师”的分级诊疗模式得到国务院医改办认可，并作为以社区为基础的医疗取代以医院为中心的医疗的模式进行推广。本研究评估了厦门市分级诊疗制度改革对慢性病患者健康结果和医疗支出的影响。

方法

数据来自厦门市电子健康记录（EHR）和医疗报销系统。样本包括 2012 年至 2016 年厦门市的 154651 例高血压患者和 50722 例糖尿病患者。因变量包括疾病控制率和总治疗费用。根据慢性病管理类型，患者被分为精准管理组、常规管理组或无管理组。采用 Kaplan-Meier 法、Cox 生存分析和 PSM+DID 方法（倾向评分匹配和差分法）比较各组的管理结果。

结果

精准管理组的临床质量表现优于常规管理组。精准管理组的疾病控制率呈持续改善趋势，而常规管理组在十个月后出现了上限效应。在精准管理组中，高血压的控制率增加了 40%以上，糖尿病的控制率增加了 30%以上，高于常规管理组的增幅。改革还与各组人均年总治疗费用的持续降低有关。2014 年至 2016 年，与无管理组相比，精准管理组高血压的节省费用为 381 元人民币，糖尿病的节省费用为 1117 元人民币。