Differences And Predictors Of Departure Ways For Discharge Patients In Sichuan Province Based On Hierarchy Medical System

ObjectiveThe objectives of this study consist of understanding the current situation of the departure ways based on Hierarchy Medical System in Sichuan province.Analyzing the differences in each dimension and existing problems of departure ways of discharge patients,identification the predictors of departure ways.And explore the problems of Hierarchy Medical System in its process,proposing suggestions for the rational departure ways,effective referral,and reducing the proportion of discharge against medical advice,then promoting the perfection of the Hierarchy Medical System.Contents1 Based on five dimensions from the lateral and longitudinal angles,including the patient,the clinical diagnosis and treatment process,the hospital,the area and the time,the present situation of the departure ways in Sichuan Province was analyzed,and the differences among the distribution of each dimension were analyzed.2 Explore the predictors of discharge against medical advice and transfer discharge from different five dimensions.3 Analyze the problems existing in the departure ways in sichuan province and explore the deficient of Hierarchy Medical System from the perspective from internal and external of health system based on system theory.4 Based on the theory of stakeholder theory and system theory,thispaper explores the countermeasures to promote the reasonable discharged ways for patients and the scientific and effective referrals.Methods1 Literature research method: systematically understanding the research status of discharged patients,sort out the factors considered in the study of patient referrals and discharging without medical advice,and provide reference for the follow-up quantitative research.2 Qualitative study: Through interviews with discharged patients and medical workers,and the three-level coding analysis was carried out by using Nvivo11 software to understand the factors related to the departure and referrals of discharged patients.3 Mathematical statistics method: The present situation of the patients' discharged ways was analyzed by Stata15.1,and the difference among the distribution of the five dimensions from the hospital,the hospital,the area and the time was analyzed.The influencing factors of the patient's non-medical advice and referral were analyzed by means of the LPM model and the multi-dimensional fixed-effect model.4 Comparative study: comparing the difference among the distribution of the discharged patients from the hospital in various dimensions,and then exploring how to promote the reasonable and effective referral for the patients.Results1 In Sichuan Province,the preferential way to leave the hospital was discharged by following the doctors' advice,accounting for 92.05%,the second place was discharging without medical advice,accounting for 5.31%,the third was the doctor's order to transfer to ‘the grass-roots units',accounting for 1.37%,and the fourth was the doctor's order to be transferred to hospital,accounting for 1.26%.2 There are great differences among the five dimensions of patients,clinical diagnosis and treatment process,hospital,area and time distribution of discharged patients in Sichuan Province.In the dimension of patients,the number of males was higher than that of females,widowed,unemployed,self-paid,elderly patients were more likely to discharge without medical advice,commercial medical insurance covered patients were more likely to leave the hospital.In the clinical diagnosis and treatment dimensions: emergency,esophageal cancer,lung cancer,cerebrovascular diseases patients with high daily hospitalization costs were more likely to discharge without medical advice,while patients who transferred from other medical institutions,surgery and the total cost of hospitalization were more likely to referral.In the hospital dimension:the workload of doctors and nurses from the normal discharge(by medical advice)is higher than the workload of the doctor and nurse from the referral hospital;the highest proportion of the non-medical discharge is the third-class hospital,the highest proportion of the discharge by medical advice is the first-class hospital,the proportion of the non-medical advice discharge of the public hospital is higher than that of the non-public hospital,the more medical devices in the medical treatment hospital have,the greater likelihood of referring to the base.3 The results of univariate analysis showed that the influence of each dimension variable on the departure and referrals of non-doctor's orders was statistically significant(P = 0.000).The results of multivariate analysis showed that there was significant correlation between sex,age,occupation,marital status,medical payment mode,admission route,length of hospitalization,discharge department,total cost of hospitalization,hospital grade,hospital nature,hospital size and whether the discharged patients left the hospital without doctor's orders and referrals,but the correlation size and direction were different.Conclusion1 In Sichuan province,there are some unreasonability in the way of discharging,the proportion of patients with referral is low,and the proportion of patients who discharge without medical advice is high.Although there achieved some results in the classification and treatment of the Sichuan Province,the proportion of the lower-to-turn ratio still needs to be improved;The proportion of discharging without medical advice for the third-class hospital and the public hospital is relatively high.2 Patient dimension,diagnosis and treatment process dimension,hospital dimension and regional dimension have different correlations with non-medical order discharging and referral.3 The problems existing in the way of discharging in Sichuan Province are the result of the internal and external deficiency of medical and health system in the process of Hierarchy Medical System.4 Starting from the internal and external factors of the medical and health service system,we should fully consider all stakeholders,and explore the countermeasures to promote the reasonable discharged ways for patients,scientific and effective referrals.SuggestionInternal(Inside the system):1 Improving the assessment methods of medical institutions and adapting the new changes of Hierarchy Medical System.2 Optimizing the level of resource allocation in Medical institutions and standardizing the referral process.3 Improving the service quality of medical workers and creating a good experience of medical treatment.4 Reforming the reimbursement process of medical insurance and increasing the degree of compatibility with the referral process.External(Outside the system):1 Perfecting relevant laws and regulations,ensuring scientific andreasonable referral.2 Broadening income channels and optimizing fee control mechanism for Hierarchy Medical System.3 Improving the level of information and enhancing the sharing of referral information.4 Strengthening publicity and education to effectively reverse the deep-rooted traditional concept of medical treatment.