| Objectives:This study is to explore the implementation strategy of two-way referral between one secondary hospital and its related community health centers in Shanghai and to analyze the performance of this referral system in order to provide the information for the decision making of two-way referral system.Methods:The contents of the study included the research on the rules and procedures of two-way referral system in one secondary hospital and its related community health centers in Shanghai and the performance evaluation of this system. Expert consults and software program writing by professionals were used in the research on the rules and procedures of the basic two-way referral system. Performance appraisal of the two-way referral system in the hospital was carried out based on the information of 465 patients in referral group and 465 patients in control group in the forms of questionnaire and referring to the case file. 237 residents in the communities were surveyed by questionnaires for understanding their cognition and satisfaction to the two-way referral system. Qualitative interviews and group discussion were conducted among medical personnel, administrative personnel and community personnel to obtain their appraisal of two-way referral system. Quantitative data base wereestablished by EpiData3.0 and statistical analyses, mainly t test and x~2 test were processed by SPSS11.5.Results:The study on two-way referral system: The indications of the two-way referral for hypertension, coronary artery disease, type II diabetes, cerebral apoplexy between one secondary hospital and its related community health centers in Shanghai were determined. Six forms of two-way referral were established, including two-way referral greenway, clinical rounds by experts, emergent consultation whenever needed, referral for rehabilitation. The pathway for two-way referral was formed between the secondary hospital and its related community health centers and the two-way referral system was improved in the form of administrative principals, ensuring measures and electronic referral network.The performance appraisal on two-way referral system: There were 966 referral visits in one secondary hospital and its related community health centers from September, 2007 to February, 2008, including 465 referral visits in the secondary hospital, 281 referral visits in A community and 220 referral visits in B community, which accounts for a low percentage of the total visits. The referral visits were mainly the visits of the patients with hypertension, coronary artery disease, cerebral apoplexy and typeⅡdiabetes, which was more than 90% of the total visits. The results showed that the effective rates of the treatment of hypertension, coronary artery disease, cerebral apoplexy and typeⅡdiabetes were 94.6%, 98.1%, 73.7% and 95.5% respectively in the out-patients in referral group and 94.6%, 90.7%, 89.3% and 97.7% respectively in the out-patients in control group. The differences between the two outpatient groups were not significant (P>0.05). The effective rates of the treatment of hypertension, coronary artery disease, cerebral apoplexy and typeⅡdiabetes were 97.2%, 98.1%, 79.5% and 97.8% respectively in the hospitalized patients in referral group, and 94.6%, 90.7%, 89.3% and 97.7% in the hospitalized patients in control group. The effective rate of the treatment for the hospitalized patients with coronary artery disease in referral group was significantly higher than that in control group (P<0.05), but there were no significant differences in the effective rates in other 3 diseases between the two hospitalized groups (P>0.05). The average cost per outpatient visit for hypertension, coronary artery disease, cerebral apoplexy and type II diabetes were 155.74 yuan, 146.58 yuan, 221.28 yuan and 167.01 yuan for the referral group, while were 150.65 yuan, 149.36 yuan, 223.65 yuan and 169.26 yuan for the control group. There were no significant differences in the average cost per outpatient visit between the two groups (P>0.05). The average cost per hospitalization for these four diseases were 8136.06 yuan, 7845.26 yuan, 10203.73 yuan and 9618.07 yuan respectively in referral group, while they were 8203.06 yuan, 8215.46 yuan, 10446.69 yuan and 9069.44 yuan respectively in control group. The differences in the average cost per hospitalization between the two groups were not significant (P>0.05). The result also showed that the satisfaction rate of the patients in referral group was 94.84% and 90.45% in control group. The satisfaction rate of the patients in referral group was significantly higher than that in control group (P<0.05). According to the investigation of the community residents, 71% of the residents preferred to visit the tertiary hospitals or secondary hospitals and only 27% of the residents preferred to visit community health centers; 70.89% of the residents knew the two-way referral system, while 28.7% of them did not.Discussion and recommendations:Through this study, the experience in the construction of two-way referral system and routine management was obtained, But, the study showed that the referral volume in one secondary hospital and its related community health centers in Shanghai was low, the medical care cost was not obviously reduced, the effect of the treatment was not improved significantly. The effect of the two-way referral system was limited. The reasons might be the absence of the first-visit system and existing problems in the two-way referral system in China. The author recommended to improve the medical insurance policy, to raise the competence of general practitioners, to speed up in training the high qualified general practitioners, to set up and improve the electronic network system of residents' health files, to establish contract system for family health services, to adjust the economic interests properly among hospitals in different levels, and to strengthen the communication among hospitals. |
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