【作者】 高倩倩；

【导师】 李士雪； 胡志；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2014， 博士

【摘要】 研究背景第六次全国人口普查数据显示,截止到2010年底全国总人口为13.7亿人,60岁及以上人口比例占13.26%(1.8亿人),其中65岁及以上人口占8.87%(1.19亿人)。与2000年第五次全国人口普查相比,60岁及以上人口的比重上升了2.93%,65岁及以上人口的比重上升了1.91%。国际上通常把60岁以上的人口占总人口比例达到10%,或65岁以上人口占总人口的比重达到7%作为一个国家或地区进入老龄化社会的标准,根据这一标准,我国已步入人口老龄化社会阶段。老年人口的快速增加,特别是80岁以上的高龄老人和失能老人以年均100万的速度快速增长,对老年人的生活照料、康复护理、医疗保健、精神文化等需求日益增大,养老问题日趋严峻。因此,无论是从保障城乡居民健康的角度,还是从政府卫生部门重点干预的角度,加强对老年人疾病负担的研究都具有重大意义。随着中央一系列的惠民政策的出台,农民的生活得到了相应的改善,但是由于以中国城乡分治为特征的二元经济结构的体制尚未受到根本触动,农村老年人仍然是中国社会生活中改善最慢的弱势群体,面临很多困难。老龄化的加快,带来一系列社会问题,其中之一是慢性病的增加。当前我国城乡居民主要死因即为慢性病,据全国疾病监测系统数据显示,自1991年开始的十年间,中国慢性病死亡人数占总死亡的比例不断上升,已经由73.8%上升到80.9%,死亡人数接近600万。农村老年人的生存环境和生活质量决定了他们对医疗服务的需求非常高,而且由于患大病的概率比较高,所需要补偿的数额也较大。当前,农村地区医药费用居高不下,疾病模式转变,人口老龄化加剧,卫生资源供应与居民卫生需求的矛盾在不断变化,新型农村合作医疗制度在农村地区虽经历了十年的发展历程,但还处于不断发展完善的阶段,新农合的实施,不仅对农民提高自己的支付能力和抵御疾病风险,而且对调节医疗机构收入构成也具有一定的积极作用。但实施新农合后,医疗费用增长显著,不仅降低了卫生资源的配置效率,而且加重了农民的经济负担。农村居民尤其是老年人面临着各种各样的疾病经济负担问题,给个人、家庭和社会带来巨大的影响。因此研究农村老年人疾病经济负担,不仅对于减轻老年人经济及精神上的负担,而且对于政府制定适宜的卫生政策,都将具有重要的理论和现实意义。研究目的通过系统回顾和总结疾病经济负担的国内外研究成果,结合现场调查资料,对农村60岁以上老年人的直接疾病经济负担进行系统分析,以理清疾病经济负担产生路径,探讨农村老年人因病导致的经济负担的水平及影响因素,提出降低农村老年人疾病经济负担的政策建议。具体研究目标包括：1.分析新农合报销补偿政策的调整与居民住院率之间的关系；2.构建农村老年直接疾病经济负担产生路径；3.描述农村老年人住院疾病及住院费用的构成情况,分析影响住院费用的影响因素,预测住院费用的未来趋势；4.描述农村老年人门诊费用的构成情况,分析影响门诊费用的直接和间接路径；5.针对疾病经济负担的产生提出降低经济负担提高健康水平的政策建议。研究方法本研究在文献综述和专家咨询的基础上,确定了研究思路,设计了研究方案和调查问卷。调取乳山市2010-2012年新农合数据库真实详尽参加新型农村合作医疗居民就诊数据,并利用调查工具采用多阶段分层抽样的方式收集了三个乡镇的1161名60岁以上老年人的一般信息、健康状况、心理状况、卫生服务利用等方面的信息。本研究对于定量资料在统计描述的基础上进行了单因素分析,并且应用多因素分析方法明确了各因素对住院费用的直接和间接效应,分析了住院费用的各构成部分的变化情况及变动方向,分析了门诊费用的影响因素和各因素之间的互相作用关系,描绘了各因素对门诊费用的直接和间接路径。本研究应用的统计分析方法包括非参数检验、递归系统模型、灰色关联分析、结构变动度分析、偏最小二乘的PLS路径分析。上述分析分别采用spss18.0和smartpls2.0统计软件实现。主要结果与发现1.疾病谱与医疗费用现状通过对2010-2012年三年来乳山市农村居民住院疾病构成分析,发现农村60岁以上老年人发病排在前五位的疾病主要为循环系疾病、呼吸系统疾病、消化系统疾病、恶性肿瘤等,且住院疾病人次数排前十位的疾病中慢性病占了三分之二以上。通过对乳山市2010-2012年三年住院费用的分析,发现农村60岁以上老年人不仅住院人次数大于其他年龄段,而且老年人住院费用占总费用的比例也高于其他年龄段,总费用和人均费用均高于其他年龄段。同时,三年来60岁以上农村老年人住院和门诊就诊人次数亦呈上升趋势。因此农村老年人的健康状况和疾病经济负担情况应引起高度重视。2.住院费用的变化随着新农合补偿政策的调整和报销比例的提高,参合农民住院率较之前有所上升。住院总费用三年来呈现上升趋势,由于基本药物制度的实施,住院费用各组成部分中,药品费比例下降较明显,取而代之的是检查化验费等出现上升趋势。通过对农村老年人住院费用分析,发现农村老年人人均住院费用构成中排在前三位的是药品费、治疗费和耗材费。就住院费用结构变动率分析结果来看,药品费、检查费、耗材费是引起乳山市农村老年人住院费用结构变动的主要费用项目,三者累积贡献率为70.53%。3.住院费用影响因素以慢性病为例,通过递归系统模型分析,发现影响农村老年人住院天数的因素依次为医院级别、是否手术、疾病种类和年龄；住院费用的影响因素依次为医院级别、住院天数、是否手术和疾病种类。其中,医院级别、是否手术、是否恶性肿瘤与住院天数和住院费用均呈正相关,即它们既可以通过住院天数影响住院费用,又能直接引起住院费用的增加；住院费用既受各因素的直接影响,又可以以住院天数为中间变量受到间接作用的影响。对于这些情况,不能简单地以一条路径下结论,故需计算其对费用的总效应,各因素对住院费用总效应计算结果大小依次为是否三级医院住院、住院天数、是否二级医院住院、是否手术、是否高血压、是否气管炎、是否恶性肿瘤、是否冠心病、年龄。分析结果与农村老年人所处的社会经济地位及现实情况基本相符合。4.门诊费用影响因素根据理论及现实意义构建的门诊费用PLS路径分析发现,构建的潜变量卫生健康状况、卫生服务利用、健康意识和心理状况四个潜变量,路径系数经检验在α=0.01水准上均具有统计学意义,说明健康状况、卫生服务利用、健康意识和心理状况因素为影响门诊费用的重要因素。根据变量赋值的意义,说明卫生服务利用越多、健康意识越差、健康状况越差、心理状况越差,门诊费用越高。各潜变量除直接作用于门诊费用外,变量之间还具有相互影响关系,各潜变量通过中间变量影响门诊费用,具体表现为：健康状况→卫生服务利用→门诊费用、健康意识→卫生服务利用→门诊费用、健康意识→健康状况→卫生服务利用→门诊费用、心理状况→健康状况→卫生服务利用→门诊费用、心理状况→卫生服务利用→门诊费用。各路径系数经检验在α=0.01水准上均具有统计学意义。结论与政策建议本研究主要结论：1.本研究样本选取合理,住院疾病负担研究所选取的样本量和样本的代表性较好。2.研究方法科学合理,适合研究对象和研究内容。3.老年人是农村住院费用重要组成部分。4.随着新农合报销比例的提高,住院率也随之提高。药品费下降的同时,检查化验费出现了上涨趋势。5.住院天数是影响住院费用的重要因素,其他因素通过影响住院天数进而影响住院费用。因此,提高医疗技术水平,控制住院天数,是降低住院费用的关键。6.门诊费用的影响因素是多维的,其作用并不是相互独立的,各变量之间是相互影响的。部分变量既是门诊费用的直接影响因素又是某些因素间接作用的中间变量,而且某些因素对门诊费用既具有直接效应又具有间接效应。7.本研究的研究结果在农村地区具有可推广性和应用性。本研究提出以下政策建议：1.政府层面---制度保障是提高卫生服务可及性的关键举措。2.医院层面---服务下沉是惠及双方实现双赢的发展方向。3.个人层面——健康意识是实现预防疾病风险特别是降低慢病风险的根本因素。4.社会层面—健康促进是实现公共卫生服务功能城乡之间差距弥合的支持因素。更多还原

【Abstract】 BackgroundThe total population of China is1.37billion people, and there are180million people over60years old accounting for13.26%by the end of2010according to the sixth national census data. The population aged65and older was119million, accounting for8.87%. Compared with the fifth national population survey in2000, the proportion of the population over increased2.93percentage points over the age of60, and over increased1.91percentage points over the age of60. Internationally the proportion of the total population over60years old to10%, or over65years the proportion of the total population reached7%is commonly accepted as the standard into the aging society, and the problem of aging populations in China is becoming increasingly prominent and rapidly increasing. The elderly aged80and older and disabled elderly increase at a rate of1,000,000annually, all of which cause a huge need of life care for the elderly, rehabilitation care, health care, spiritual culture.Therefore, whether it is from the standpoint of protecting urban and rural residents’ health perspective, or from the perspective of government intervention in the health sector focus, strengthening the research on the disease burden of the elderly is of great significance.Although the policies benefiting the people that are carried out by the government. The life of farmers have been corresponding improvement.However,due to the dual economic structure of the urban and rural area, the elderly in rural area are still among the most vulnerable group, which improves slowly in Chinese society, so they face a lot of difficulties.Increasing aging problem brings a lot of social problems, one of which is the increase of chronic diseases. Currently, chronic diseases have become the leading cause of death in urban and rural residents. The national disease surveillance system data shows that the chronic disease deaths proportion of total deaths has continued to rise in China from1991to2000,(73.8%to80.9%), and the mortality is nearly six million. Farmers’demand for medical services is huge because of their living environment and life quality, and probability of suffering from a serious illness is high, so they required amount of compensation.Currently, the expense of medicines in rural areas is high, and the disease pattern is changing. At the same time, the aging population is increasing, and the conflicts between the supply and demand of health resources of residents are changing. The New Rural Cooperative Medical System in rural areas has developed for ten years, but it still needs improved. The New Rural Cooperative Medical System (NCMS) is implemented to improve the capacity of farmers’ actual capacity to pay for health services and resistance to disease risk. While it also has some positive effects for health institutions to adjust revenue constitute. But after the implementation of the NCMS, the medical expense increased significantly, it not only reduces the allocate efficiency of health resources, but also increased the financial burden of farmers. The rural residents especially the elderly face various financial burdens of disease problems, which have a huge impact on individuals, families and the society. Therefore, the research of the disease economic burdens of the elderly in rural areas has important theoretical and practical significance not only for reducing the burden on the elderly mentally, but also for the government to develop appropriate health policy.Research ObjectivesThe research systematic analysis the direct economic burden of disease on the rural elderly residents, through systematic review and summarize the research achievements of economic burden of disease at home and abroad and field survey data. Its aim is to sort out the path of the economic burden of disease, to investigate the level and influencing factors of the economic burden of illness of the rural elderly, to puts forward the policy recommendations for reducing the economic burden of disease of the elderly in rural areas。 Specific objectives including: 1. To analysis of relationship between the NCMS reimbursement policy adjustment and the rate of hospitalization of Residents.2. To construct the theoretical framework of the Path generation which comes from the direct economic burden of the rural elderly3. To describe the rural elderly inpatients diseases and hospitalization expense, to analysis of the factors affecting hospitalization expense, to predict the future tendency of hospital expense4. To describe the composition of the outpatients expenses of the rural elderly in rural areas, analysis the direct and indirect path of the outpatients expenses.5. To put forward the policy recommendations for reducing the economic burden of disease and improving the health level according to the related factors to produce the economic burden of diseaseResearch MethodsThe paper identified research ideas and designed study and questionnaires on the basis of literature review and specialist consultation. After getting the data from the NCMS database of Rushan city during2010to2012, this paper collected the information of elderly people above60years old including general information, health status, mental status and health care utilization in three villages by using survey tools,1067rural elderly people above60years old in Rushan City were selected as respondents by multistage sampling。On the basis of statistics description this study analyzed the quantitative data by using single factor analysis method, and analyzed the direct and indirect effects of various factors on hospital expenses, and analyzed changes and trends of each component of hospital expenses by using multi-factor analysis method, and analyzed the interaction of factors of outpatient expenses and each factor, and depicted the direct and indirect paths of various factors on the expenses of outpatient. The statistical methods in this paper included the non-parametric test, recursive model system model, grey relational analysis, the degree of change in structural analysis, PLS path model based partial least squares analysis. This paper made use of spss18.0and smartpls2.0statistical software to achieve these analyses.The main results and findings:1.The Status of disease spectrum and medical expenses By analysis the spectrum of the inpatient2010-2012years in Rushan city, we found that in the top five diseases were circulatory system disease, respiratory system disease, digestive system disease and malignant tumor and so on of the rural elderly above60years old, and the number of people with chronic disease inpatients row of the top ten diseases accounted for more than2/3.Through analysis the hospital expenses in2010to2012,we found that Not only did the rural elderly above60years old hospitalized expenses more than other age groups, but also the hospitalized expenses accounted for the proportion of the total costs higher than that of other age groups. The total expenses and the average expenses are higher than other age groups. At the same time, the inpatients and outpatients number of rural elderly above60years old also shows ascendant trend.therefore, health and disease burden of rural elderly people should be pay more attention to the rural elderly above60years old.2. Changes of hospitalization expensesWith the adjustment of NCMS reimbursement policy and reimbursement ratio increased, the hospitalization rate of the farmers increased than before. For three years old, the hospitalization expenses shows a rising trend.Since the implementation of the basic drugs, the proportion of drug fees decreased obviously, but examination fees have been on the rise in the hospitalization expenses of each part, Through the analysis of the hospitalization expenses for the elderly in rural areas, we found that the top three are medicine fee, treatment fee and supplies fee in the average hospitalization expenses of the elderly in rural areas. At structure change rate level, the medicine fee, examination fee, and material fee are main project which caused the structure changes of the hospitalization expenses in the rural elderly in Rushan city. The cumulative contribution rate was70.53%.3.The analysis of influence factors of inpatientsThe chronic disease as an example, the analysis through the recursive model reveals that the main influencing factors which Influenced hospitalization expense of rural elderly chronic diseases are hospital level, hospitalization days,whether the operation and the types of disease. Among them, hospital level, operation or not, whether the malignant tumor and the hospitalization days and expenses of hospitalization were positively correlated, They not only through influencing hospitalization expenses, but also directly cause the increase of hospitalization expenses. The results show that the total effect of impact on hospital expenses is secondary hospital, hospitalization days, tertiary hospital, malignant tumor, operation, hypertension, bronchitis, age, cerebral infarction and cerebral vascular disease according to the size of the order, and the analysis results are in accordance with the position and the reality of the rural elderly located.4. The analysis of influence factors of outpatients expensesThe outpatient expenses constructed by theoretical and practical significance according to PLS path model, we found that the path coefficients of health status, healthcare utilization, health awareness and psychological conditions were statistically significant at a=0.01level which showed that health status, healthcare utilization, health awareness and psychological conditions were important factors affecting outpatient expenses. According to the meanings of variables, it indicated that more healthcare utilization, worse health awareness, worse health status and worse psychological conditions would brought about higher outpatient expenses. In addition to the direct effects of each latent variable on outpatient expenses, there were relationships between each other. The latent variable affected outpatient expenses by intermediate variable which followed that:health status→healthcare utilization→outpatient expenses,health awareness→healthcare utilization→outpatient expenses,health awareness→health status→healthcare utilization→outpatient expenses,psychological conditions→health status→healthcare utilization→outpatient expenses,psychological conditions→healthcare utilization→outpatient expenses. Each path coefficients was statistically significant at a=0.01level.Conclusions and political recommendationsThe main conclusions of this study were:1. The study sample is reasonable, the sample were assumed to be representative.2. The method is scientific and reasonable, it is suitable for study object and the research content.3. The elderly were important part of rural hospital costs;4. With increase of NCMS reimbursement ratio, hospitalization rates also increased, and with dropping of drugs fees, check and laboratory fees showed rising trend;5. The days of hospitalization was an important factor affecting hospital costs, and other factors affected hospital costs by affecting the days of hospitalization. Therefore, raising the level of medical technology and controlling the days of hospitalization were the keys to reduce hospital costs.6. Factors of outpatient expenses are multidimensional and they were not independent but interacted. Some variables were both direct factors of hospital expenses and mediate variables of some factors, while some variables had both direct effects and indirect effects on hospital expenses.7. The results of this study can be popularized and applied in rural areas.This study proposed the following policy recommendations:1. Government level-system security is key initiative to improve health service;2. Hospital level-Service sink was development direction of benefiting both sides to achieve win-win.3. Individual level-Health awareness is the fundamental factor in prevention of disease risk particularly chronic disease risk;4. Social level-Health promotion is the support factors to narrow the gap of public health services between urban and rural areas.更多还原