基于离散选择实验的我国慢性病患者中医药服务利用效用及供给策略研究

With the advent of new human disease spectrum, an aging society, and the surging incidence and number of chronic diseases, chronic disease management strategies cannot meet the demands of health medicine changing. Chinese Traditional Medicine with national features has not yet play an important role in chronic diseases prevention and control, to a great extent, relative policy and strategies superiority do not paid full attention to chronic patients’ preferences largely. We try to explore content and element of the health care utility value by literature review, normative analysis. Based on the initial research outcome, we identify attributes and the level of factors With the advent of new human disease spectrum, an aging society, and the surging incidence and number of chronic diseases, chronic disease management strategies cannot meet the demands of health medicine changing. Chinese Traditional Medicine services with national features has not yet play an important role in chronic diseases prevention and control, to a great extent, for we do not pay full attention to chronic patients’ utility largely. We try to explore content and element of the health care utility by literature review and normative analysis. Based on the initial research outcome, we identify attributes and the level of factors that chronic patients’ utility for Chinese Traditional Medicine care by experts’ in-depth interviews and literature review. A limited choice sets and questionnaire will be developed using Discrete Choice Experiments (DCE) and orthogonal. The data is collected through questionnaires in 36 sample communities/townships in Shanghai, Jiangsu, Hubei, Henan, Sichuan and Guizhou et al areas. Coefficients of attributes of patients’ utility could be attained by conditional multivariable Logit regression analysis, and its factors are explored by Hierarchical Multiple Factor Analysis. Then chronic diseases innovative delivery strategy and model for Chinese Traditional Medicine care should be come up with from diversified levels, types, providing bodies by semi-structured interviews and comparative analysis.

随着人类疾病谱的改变和老龄化社会的到来，慢性病发病率和罹患总人数呈现急剧上涨之势，现有的慢性病防治策略和模式已不适应健康医学模式的转变。具有民族特色的中医药在慢性病防治过程中的优势和作用未发挥出来，与未充分重视慢性病患者中医药服务利用效用有关。本项目通过文献研究、规范分析法探讨患者服务利用效用内涵及要素，结合专家咨询和文献分析法拟定慢性病患者中医药服务利用效用的属性特征和水平，利用正交设计和离散选择实验（Discrete Choice Experiments，DCE）设计调查工具，通过分层随机抽样法在上海、江苏、湖北、河南、四川和贵州等6省市的36个样本地区的社区或乡镇收集资料。首先利用条件Logit回归法量化患者服务利用效用，再用分层多重因子法分析效用的影响因素，最后通过访谈法和比较分析法，从不同层次、类型、服务主体等角度，提出构建多元化慢性病中医药服务供给策略的建议。

本研究通过文献研究法评估了我国中医药服务供给和利用现状以及国内外对于居民医疗服务选择的研究现状，通过离散选择实验设计纳入了医疗服务模式、治疗方案类型、医生级别、获得医疗服务所需的交通时间和单次就诊的支付费用五个属性，运用Mixed Logit模型、亚组分析、类潜变量分析、交互作用模型等方法测量了居民在轻度和重度慢性病假设下医疗服务利用效用及群体和个体异质性。最后结合研究现状、离散选择模型分析结果、实地调研及专家咨询结果，提出了多元化慢性病中医药服务供给策略。主要发现与结论：①我国中医药服务体系构建已较为成熟，然而在服务提供中仍存在中医资源区域配置不合理、基层中医药服务能力弱、中医预防保健体系有待完善等问题，在利用中存在利用不足的问题。而针对这一问题，目前相关研究并未从患者偏好角度给予分析与讨论。②居民在慢性病假设下总体不倾向于选择中医服务，但对中西医结合的医疗服务接受度高，异质性小。③轻度慢性病假设下居民总体偏好距离近和费用较低的医疗服务。④重度慢性病假设下居民总体偏好专家、专科服务，反映了居民在疾病严重时愿意购买高质量、高价格、距离近的医疗服务。但愿意为了高质量的医疗服务放弃对近距离属性的选择。⑤农村居民和城市居民相比，在轻度疾病假设下更倾向于选择距离近的医疗服务，在重度疾病假设下更倾向于选择专科和专家服务。针对主要结论，我们提出了如下建议：①构建供给侧改革下慢性病医疗服务供给策略。落脚于提供高质价优的医疗服务，完善推进分级诊疗制度建设，引导全科医疗在基层慢性病服务提供中进一步发挥作用，促进医疗资源在空间上的合理布局，为慢性病患者提供同质化服务。②构建基于居民偏好的慢性病中医药服务供给策略。加强中医预防保健服务；中西医结合，促进中医医疗服务体系结构完善，加强基层中医药服务能力建设。