1 临床资料 患者,男,65岁,因"咽部不适1年余,进行性加重2周"入院.患者1年前出现咽部不适,无咽痛、声嘶,近2周出现饮食饮水呛咳,遂至潍坊市人民医院耳鼻咽喉科行钡餐检查示(图1A):食管上端前部有一较大的囊袋样憩室充盈,压迫局部食管变窄,钡剂通过受阻、部分造影剂逆行向前上方反流进入喉及气管和支气管内.后为求进一步治疗就诊于我院胸外科门诊,以"食管憩室"收治入院.

目的 研究我国妇产科资源配置与服务利用情况,并做出综合评价.方法 依托《2020中国卫生健康统计年鉴》中2019年妇产科服务需要、资源、利用三方面的相关数据构成的9项评价指标,运用TOPSIS法和卫生服务三维评价模型对我国妇产科资源配置现状和服务利用情况进行描述分析.结果 在妇产科服务需要方面,西部地区对妇产科资源的需要相对较高,Ci指数为0.0636,中部和东部地区相对较低,Ci指数分别为0.3095和0.0976;在妇产科资源配置方面,西部和东部地区资源投入相对中部地区高,其Ci指数分别为0.3451、0.2960和0.1861;在资源利用方面,东部地区对妇产科资源利用水平较高,Ci指数为0.4156,中西部地区利用较低,Ci指数分别为0.2679和0.2792.结论 全国32.26％的省份妇产科服务需要较高、资源投入过低、利用不足,有19.35％的省份存在妇产科服务需要过高、利用不足和资源"虚高"的问题,相关部门应重点关注,促进妇产科保健资源配置的提质增效,提高资源利用率.

目的 探讨鼻内镜手术及联合围手术治疗不同临床表型的慢性鼻-鼻窦炎(CRS)的临床疗效.方法 选取收治的慢性鼻-鼻窦炎的患者200例,根据鼻腔病变组织病理结果分为嗜酸性粒细胞增多组(ECRS组)及非嗜酸性粒细胞增多组(non-ECRS组).两组患者均先行3个月的非手术治疗.对未能治愈的患者行鼻内镜手术治疗.此外将ECRS组手术患者随机分为两组,一组患者直接行手术治疗,另外一组患者术前给予口服泼尼松2周.分析比较各种手术患者相应的手术相关指标以及临床疗效.结果 经过3个月的非手术治疗后,ECRS组总有效率(3.75％)低于non-ECRS组(36.67％)(P＜0.05).在手术患者中ECRS组与non-ECRS组在手术相关指标以及临床疗效上也均存在统计学差异(P＜0.05).结论 功能性鼻内镜手术联合围手术期治疗对non-ECRS患者疗效较好,对ECRS患者疗效较差,且ECRS患者术后易复发.

Family physicians contracted service is an important choice to deepen the reform of China′s healthcare reform and achieve the strategic goal of " health for all" . In order to effectively promote the contracted service, the central government has successively issued a number of policy documents, which are echoed by the localities in their proactive explorations, achieving remarkable results. But there are also multiple roadblocks hindering the contracted service to progress. This article referred to the three-circle theory and studied policy implementation from the three dimensions of policy value, policy resources, and policy impetus. A thorough analysis of the problems in the implementation process revealed such main problems as insufficient family physicians, inadequacy of supporting policies and low level of policy acceptance among the young healthy age groups. The follow-up work will promote the long-term implementation of the family physicians contracted service policy by enriching the family physicians team, enriching supporting policies, and focusing on promotions to key age groups.

[目的]了解我国居民健康素养水平现状,分析其影响因素,为提高健康素养水平提供对策建议.[方法]采用多阶段分层抽样的方法,于2019年3-4月选取日照市岚山区和五莲县居民进行调查,采用t检验和方差分析对不同人口学特征居民的健康素养进行比较,采用多元线性回归对居民健康素养的影响因素进行分析.[结果]日照市居民健康素养得分为(27.43±12.55)分(总分74分).3个方面健康素养标化后得分依次为基本知识和理念素养(16.97±7.43)分、健康生活方式与行为(13.20±6.42)分、基本技能(12.64±7.76)分;6类健康问题素养标化后得分依次为:安全与急救(8.36 ±4.24)分、科学健康观(8.09±4.20)分、基本医疗(7.87±3.41)分、传染病防治(7.96±4.13)分、慢性病防治(6.13±3.46)分、健康信息(4.93±4.08)分.在健康素养水平、3个方面健康素养水平以及6类问题素养水平方面,女性低于男性,70岁以上年龄组的居民最低,农村居民低于城市,文化程度越低水平越低,家庭人均年收入越低居民的水平越低.多元线性回归结果显示,年龄组与健康素养得分呈负相关(t=-6.777,P＜0.01),常住地(t=6.571,P＜0.01)、文化程度(t=10.831,P＜0.01)、家庭人均年收入(t=4.053,P＜0.01)与健康素养得分呈正相关.[结论]我国居民健康素养水平稳步提高,但仍具有提升空间.日照市居民健康素养较低,老年人、常住地在农村、文化程度低且家庭人均年收入低的居民健康素养偏低,建议通过拓宽健康教育渠道,加强健康知识的宣传,培养居民的健康意识,提高居民自我保健、应急技能等方面的能力提高居民的健康素养.

<span id="ChDivSummary" name="ChDivSummary" class="abstract-text">目的:确定医联体发展模式中共性的动力和阻力,进一步增强发展动力、减弱发展阻力,从而为促进医联体良性发展提供参考。方法:以"CNKI"和万方数据库为检索对象,以"医联体"或"医疗联合体"或"医共体"为主题词,最终检索得到文献3173篇,并在此基础上对筛选后的247篇文献进行计量分析。结果:医联体的文献数量从2013年开始逐年增加;文献研究者层次较高;文献研究的问题地域范围广泛,全国范围的问题占53.0%;政策推进和问题导向是医联体发展的主要推动力,其中国家出台的系列政策和指导意见推动作用最为突出;患者传统的就诊习惯难改变以及配套政策不健全是医联体发展的主要阻力。结论:国家将医联体建设作为分级诊疗制度建设的重要抓手,出台卫生政策和指导意见推动医联体发展;当前医联体发展阻碍力较多且关键阻碍力作用显著,其中患者认可度低是限制发展最大的阻碍力。应进一步完善制度采取措施减弱阻力增强动力。</span>

Objective:To explore the current status of village doctors′ vulnerability in Shandong province in the context of ongoing healthcare reform.Methods:A cross-section study was conducted from October 2015 to November 2015 based on a self-designed questionnaire for village doctors. The questionnaire included 6 parts: fundamental state, disturbance from surroundings, disturbance from job, emotional support, instrumental support and self-ability of village doctors. Mean and standard deviation were adopted to describe the level of disturbance and support. Quadrant analysis was adopted to analyze village doctors′ vulnerability. The set pair analysis was adopted to calculate the vulnerability index and sample cluster analysis was adopted to classify village doctors based on the vulnerability index.Results:The total disturbance score was 3.39±0.46, and contribution from professional risk was the biggest(19.95%). The self-ability score was 3.33±0.40, and contribution from financial support was the smallest(4.09%). According to the set pair analysis, village doctors′ vulnerability total score was 0.49±0.06, ranging in a medium category. According to the sample cluster analysis, 27.2%(277/1 018)of the village doctors stayed at the upper category, as 30.3%(309/1 018) was defined as a medium category. According to the quadrant analysis, 35.5%(361/1 018)of the village doctors were found as in crisis vulnerability.Conclusions:In general, village doctors′ vulnerability stays in the medium category. They have to fight against high disturbance from surroundings, with more emotional support and less financial support expected.

背景家庭医生签约服务在提高基层服务能力、满足居民就医需求、落实分级诊疗制度等方面发挥了积极作用,但政策执行过程中履约质量不高、居民认可度不高、家庭医生工作积极性偏低等问题逐渐凸显,如何优化和保障家庭医生政策的实施成为基层改革的焦点问题.目的探讨我国家庭医生政策执行困境,并提出相应的消除路径,以期为完善家庭医生制度提供参考.方法 本文检索自2016年以来,由国务院、国家卫生健康委等部门发布的有关家庭医生的政策文件,并以“家庭医生”为主题词,检索中国知网、万方数据知识服务平台、维普等数据库,剔除重复、无关等文献,最终纳入合格文献1 393篇.同时以2015-2017年《中国卫生和计划生育统计年鉴》、2018年《中国卫生健康统计年鉴》及2018年我国卫生健康事业发展统计公报的相关数据作为定量资料来源.在此基础上,运用模糊-冲突理论,从政策目标和政策手段的模糊性、政策参与主体间的冲突性、政策执行中的支配性因素等方面,对家庭医生政策执行困境进行分析.结果 家庭医生政策的模糊性逐步降低,政策参与主体间的冲突性仍较为显著,主要表现为政府的愿景规划与居民的就医模式存在差距、上下级医院存在利益协同困境、家庭医生对政策认可度不高.同时,政策执行过程由象征性执行向政治性执行转变,支配性因素也由联盟强度转变为权力.结论 家庭医生政策执行情况未达到预期效果,政策目标地区差异性较低、基层服务能力不强、利益分配与补偿机制不健全、法律保障缺失和资源配置不充足等影响政策执行效果.应从调整政策目标和手段、明确各级医疗机构及医务人员间的利益分配和分工协作机制、改善居民签约服务获得感、完善政策的法律保障、调节卫生资源配置结构等角度破除政策执行过程中的困境.

目前我国尚未建立具体的长期护理保险制度,理论研究取得一定成果,实践上仍处在试点阶段.运用文献研究法,对比分析对法美国、德国、日本、韩国4国长期护理保险制度的建立背景、模式特点与运营机制、资金筹集方式给付方式和服务提供内容展开论述,基于国外的先行经验结合我国社会经济现状提出:实行多渠道的筹资扩大覆盖范围,设立全国统一的长期护理保险需求分级和等级评估标准,鼓励发展商业长期护理保险、补充完善长期护理保险体系等建议,以期为我国建立长期护理保险制度提供参考.

<span id="ChDivSummary" name="ChDivSummary" class="abstract-text">目的对我国中医资源配置和服务利用情况进行综合评价,为促进中医事业的发展提供政策依据。方法运用TOPSIS法和因素重要性推导模型,对中医资源配置与服务利用等情况进行综合评价。结果从中医资源配置情况来看,四川中医资源配置水平最高,Ci值为0.5862,海南中医资源配置水平最低,Ci值为0.0317;从中医服务利用情况来看,北京中医服务利用水平最高,Ci值为0.9246,山西中医服务利用水平最低,Ci值为0.0279;从综合评价结果来看,中医资源配置和服务利用类型中"低资源、低利用"所占比例最大,为48.39%。结论上海、宁夏、新疆属于"低资源、高利用"型,居民的中医服务需要未能得到有效地满足,辽宁、山西、河北、山东、湖南、内蒙古属于"高资源、低利用"型,中医资源利用率不高,存在浪费的风险。针对不同的类型,政府及相关部门应采取不同的措施,实现中医资源优化配置,提高居民对中医服务的利用。</span>

Objective:To explore the formation mechanism of the weakening of village clinic′s medical service capacity in the context of new medical reform.Methods:Purposive sampling method was used to enroll 38 rural doctors and managers of rural health centers and health offices in the interview from October 2015 to November 2015. And grounded theory was adopted to analyze reasons and their mechanism of the weakening of village clinic′ s medical service capacity.Results:29 first-grade categories and 7 second-grade categories were worked out in text encoding. With the implementation of the ongoing healthcare reform, support from financial, policy and technology increased significantly, but due to the synthetic action of unexpected negative effects of the reform, superposition and accumulation of disturbance and ineffective support, village clinic′ s medical service capacity began to weaken.Conclusions:The weakened village clinic′ s medical service capacity is a result of the synthetic action of 3 reasons. The persistence of this status will intensify the vulnerability of rural health service system and be bad for the implementation of hierarchical medical policy and the strategy of rural vitalization. Measures should be taken to optimization the essential medicine system, establish a comprehensive assessment mechanism for basic medical service and basic public health service of village clinic, strength the strategic purchasing of medical insurance, improve the financial compensation mechanism, and complete training system of village doctors, aims to promoting sustainable development of village clinic.

Objective To analyze the dilemmas of our hierarchical medical system, in order to seek a viable path for effective implementation.Methods Based on the Meter-horn model, six related factors were used, including policy standards and goals, policy resources, implementation methods, characteristics of the actuator, value orientation of the executive and the system environment, to analyze the dilemmas of the implementation of hierarchical medical system.Results This policy had not achieved the expected effect in the implementation process, which deviated from the original intention of policy designers to some extent. There exist the following setbacks for the roadblocks. For example, policy standard was ambiguous, the policy resources were insufficient, the execution method was not proper, the implementation mechanism was"criticized" , the implementation personnel value orientation was biased and the complex system environment.Conclusions All the factors involved in the implementation of the hierarchical medical policy affect each other.In this consideration, medical institutions at all levels and the relevant departments should coordinate and deal with the relationship between these six related factors, and timely take effective measures to amend and improve the policy, so as to ensure the orderly progress and long-term implementation of the hierarchical medical system.

[目的]探究全面二孩政策实施后育龄期女性的二孩生育意愿及其影响因素.[方法]于2018年6-7月采用多阶段分层随机抽样方法在山东省聊城、 青岛、 潍坊3市共抽取600名二孩育龄期女性进行问卷调查,并运用描述性分析、 χ2检验、Logistic回归分析等方法对调查结果进行分析.[结果]调查的600名二孩育龄期妇女中,有二孩生育意愿的有219人(36.50％).单因素分析显示,不同人口学特征(城乡差异、 年龄、 文化程度、 收入)的育龄妇女二孩生育意愿差异有统计学意义(P<0.01);Logistic回归分析显示,户籍、 年龄、人均月收入、 经济负担、 工作压力、 对二孩政策的态度以及家庭成员的生育观念等均为二孩生育意愿的影响因素(P<0.05).[结论]山东省育龄期女性生育二孩的意愿较低,二孩生育形势仍不乐观.建议加强对政策的宣传,积极鼓励生育二孩,确保职业女性的工作权益并完善教育、 医疗等与政策配套的社会福利保障制度,从而减轻育龄期女性的抚育压力,真正提高山东省育龄女性的生育意愿.

目的:通过分析影响医联体核心医院与患者行为策略选择的因素,以明确双方的最优稳定策略及其产生条件,从而进一步提出引导双方行为策略的措施,以期为推进医联体建设提供参考.方法:基于演化博弈理论及政策文本分析,构建核心医院与患者的博弈模型,并运用进化稳定策略和复制动态方程,对模型进行求解分析.结果:核心医院的最优稳定策略是“帮扶基层加强能力建设”,选择该策略的概率主要与政府的支持程度、运行成本、收入结构等因素相关;患者的最优稳定策略是“遵循基层首诊”,选择该策略的概率主要与基层就医获得感等有关.结论:从建立合理的财政补偿机制、完善相应的配套措施、加强基层能力建设等角度,引导核心医院与患者选择最优稳定策略.

目的 了解女大学生医疗健康类APP利用行为及影响因素,为提高女大学生医疗健康保健行为和提升健康水平提供参考依据.方法 采用分层随机抽样方法抽取潍坊市3所高校891名女大学生进行问卷调查,调查女大学生自身健康关注情况、医疗健康类APP知信行现状,采用Logistic回归分析进行影响因素分析.结果 55.4％的女大学生使用过医疗健康类APP,且多集中在健身减肥类APP(290人次),不同学历、不同专业、不同年级学生利用率差异均有统计学意义(x2值分别为26.55,7.72,13.96,P值均＜0.05).Logistic回归分析显示,学历、年医疗花费、医疗健康类APP认知度、对APP前景态度是医疗健康类APP利用的影响因素(OR值分别为0.44,0.69,1.36,1.23,P值均＜0.05).结论 医疗健康类APP利用率一般,持续使用率较低,APP应丰富内容,增设视频推荐、互动交友等功能,使女大学生更好地利用医疗健康类APP.

目的 通过分析评价2015-2017年我国各地区社会剥夺水平,测算各地区妇幼保健机构人员配置的公平性缺口,以期为妇幼保健人力资源的合理配置提供参考.方法 在运用主成分分析确定各剥夺指标权重的基础上,采用总体剥夺指数和公平调节构成指数确定各地区社会剥夺水平及应获得的资源比例,以此计算各地区妇幼保健机构所需人数与实际人数的差值明确其公平性缺口.结果 2015-2017年我国各地区总体剥夺指数的取值范围分别为-1.666～1.720、-1.550～ 1.808、-1.613～1.553,妇幼保健机构人员配置公平性缺口的取值范围分别为-17 904～9 855、-19 627～10 271、-22093～ 12 369;人员配置的公平性缺口整体呈现上升趋势,但地区间变化形式不一;总体剥夺指数对地区妇幼保健人员配置公平性缺口值存在正向影响.结论 总体上看,我国妇幼保健机构人员配置的公平性较差,应根据各地社会剥夺水平、人口规模、服务需求以及人员专业素质等要素,从加强人员流动、提升服务水平、提高部门协同等方面进行人员合理配置.

Objective To systematic review the influence of case-based payment on inpatient costs since China′s new medical reform. Methods Studies about inpatient costs before and after the implementation of case-based payment were collected. The literature collected underwent a meta-analysis by RevMan 5. 0. Results A total of 11 articles in compliance were included in the study. The meta-analysis of random effect model showed the overall effect size (SMD) was -1. 54 with 95% CI being -1. 79, -1. 29, showing a significant difference (P<0. 05). The subgroup analysis showed that the overall effect size (MD) in the low-cost disease group was -585. 57 yuan with 95% CI being -750. 34, -420. 80, showing a significant difference (P < 0. 05). The overall effect size (MD) in the high-cost disease group was-4 172.65 yuan with 95% CI being -5 368. 21, -2 977. 10, showing a significant difference ( P <0.05). The funnel plot was approximately symmetrical, suggesting a publication bias as less likely in the study. Conclusions The implementation of case-based payment has reduced the inpatient costs to some extent thanks to China′s new healthcare reform. And the effect in the high-cost disease group was more obvious than that in the low-cost disease group.