我国农村地区慢性病患者分级诊疗的行为经济学模型及政策优化研究

Objectives: Chronic diseases have become a major health problem in rural China. Previous studies showed that patients’ behavior is the one of most important cause. However, we don’t understand the irrational behavior of patients in the process of screening, treatment and rehabilitation. To solve the problem, the study aims to construct the model of behavioral economics of chronic disease patients under the hierarchical diagnosis and treatment system based on the theory of behavioral economics. The model will reveal the mechanisms between the impact factors of behavioral economics, decision-making behavior and performance of chronic disease patients. The mechanisms will provide a theoretical framework and scientific basis for the optimization of choice architecture, the policy of the hierarchical diagnosis and treatment system and management of chronic diseases...Design/methods: The study will collect data of hypertensive patients from three counties, nine towns and fifties four villages of Shandong Province, an eastern area in China. In order to construct the behavioral economics model and identify the decision-making process, the study will conduct the key interviews and focus group discussions of the investigation of government, township hospitals and village clinics. In order to confirm the patients’ behavior, the study will conduct the household survey of 2160 hypertensive patients. ..Expected Results/ policy implications: The study is expected to fill the gap in the research of behavioral economics of chronic disease management, to enrich the evaluation method of public health policy. In addition, the study will help policy-makers to indentify constraints of choice architecture faced by different decision-making and to improve the policy of the hierarchical diagnosis and treatment system.

慢性病已经成为我国农村居民面临的重大健康问题。现有研究表明患者行为是造成此问题的重要原因，但是对于患者在筛查、治疗和康复过程中的非理性行为还缺少理解。针对该问题，本项目将基于行为经济学理论，从慢性病患者分级诊疗决策过程角度，研制慢性病患者分级诊疗的行为经济学模型，揭示慢性病患者行为经济学因素、决策行为以及绩效之间的作用机制，为分级诊疗政策和慢性病管理的决策环境、政策优化提供理论框架和科学依据。为了完成上述研究目标，本项目拟以高血压患者为研究对象，选择在山东省3个县9个乡镇54个村开展政府、乡镇卫生院、村卫生室机构调查以及2160名患者家庭入户调查。调查将采用关键人物访谈、焦点小组讨论、调查问卷、病案调查等方式收集资料。本项目预期将在理论上填补国内慢性病管理行为经济学研究的空白，丰富公共卫生政策的评价体系，并为完善分级诊疗政策以及优化慢性病管理的社会环境做出贡献。

研究背景.慢性病分级诊疗体系不仅关系到慢性病管理，也关系到分级诊疗体系的完善。但是，慢性病人健康行为及就医决策存在大量非理性，这导致他们有时无法做出对自己健康有利的选择。已有研究主要从稀缺的物质资源分配角度来分析这一问题，而对于医生和慢性病人的有限理性、有限意志力和有限自利这种稀缺的认知资源的分配缺少研究。行为经济学对于研究稀缺的认知资源的分配已经形成了相关理论、模型和方法。因此，本项目研究了慢性病分级诊疗的行为经济学模型和优化策略。.研究内容.本项目建立了行为健康经济学研究体系，构建了慢性病分级诊疗体系的透镜心理模型、决策行为模型、短期决策行为前景理论模型、长期决策行为跨期选择模型，并对高血压患者治疗依从性行为经济学模型进行了实证研究。最终，本项目提出了慢性病分级诊疗决策的路径和决策环境优化的建议。.重要结果和关键数据.慢性病分级诊疗体系医疗机构和患者认知资源均有限，导致他们医疗决策会出现与期望效用理论不一致的行为。医生的医疗决策思维由药师、医疗保险人员来审核，有利于减少医疗错误，减少医疗保险费用的浪费。对于高血压患者来说，在保持其他变量不变的前提下，年龄越大，治疗依从性越高；高血压越严重，治疗依从性越高；代表性偏差、时间不一致偏好、心理账户对高血压治疗依从性起负面影响；社会规范、默认选项对治疗依从性有正面作用。.科学意义.慢性病分级诊疗体系构建相关的行为经济学模型有助于完整描述医疗机构和慢性病患者的医疗决策认知障碍，从而有助于采取助推、助力、行为设计等行为公共政策方法来针对不同理性状态的高血压患者精准施策，推动健康中国建设政策的落地。