【作者】 颜艳；

【导师】 孙振球；

【作者基本信息】 中南大学 ， 卫生统计与流行病学， 2007， 博士

【摘要】 第一篇长沙市社区老年居民健康状况及社区卫生服务需求与利用现状研究目的:在国家自然科学基金资助项目《城市老年人社区卫生服务最小数据集研究》总体设计方案指导下,本研究旨在通过长沙市社区老年居民人口结构、健康状况以及对社区卫生服务的需要和需求意愿的调查,分析居民利用社区卫生服务的影响因素,了解社区卫生服务的可及性,为长沙市老年人社区卫生服务转向以需求为导向的发展方向和发展模式提供基线数据和政策依据,并为建立城市老年人社区卫生服务信息管理的基本数据集的研究提供现场研究资料和统计学依据。方法:采用多阶段随机整群抽样的方法选择研究人群,通过横断面调查的方法获取以下基本数据:①长沙市被调查老年居民的健康状况与卫生服务需要情况,包括社区居民社会经济人口学特征、两周患病情况、慢性病患病情况、医疗保健情况等;②老年居民社区卫生服务实际利用情况;③老年居民对社区卫生服务需求意愿。运用描述性分析法、比较分析法、协方差分析法及logistic逐步回归分析法对调查资料进行统计分析。结果:本研究在长沙市开福区、天心区和岳麓区随机抽样并入户调查了6个社区居委会的老年居民,实际调查人数630人,有效问卷602份,有效率为95.6%。其中,男性占41.2%,女性占58.8%。研究结果显示:被调查社区老年人两周患病率为52.0%,两周未就诊比例为46.0%,自我医疗占病人比例为51.4%,48.6%的老年居民由于经济困难而没有对疾病采取任何治疗措施。慢性病患病率按病人数计算为56.3%,按病例数计算为100.8%,一人患两种及三种慢性病占全部患者的比例为54.9%。70.9%的老年人距离就诊地点在1公里以内。8.3%的老年居民的医疗保健知识来自于就诊的医生。老人社区卫生服务的综合利用率为40.4%,11.0%的老人生病时无人照顾。协方差分析分析表明,慢性病与SF-36各维度得分均有紧密的联系。单因素分析表明,对卫生服务中心不了解、卫生服务站的功能不齐全以及不能报销均限制老年人对社区卫生服务的利用。多因素分析结果表明,经济收入和社区卫生服务知晓程度是影响老年人利用社区卫生服务的主要因素。研究还表明,两周患病率、慢性病患病率用于老年居民健康状况和卫生服务需要的评价存在下列问题:①两周患病率和慢性病患病率的logistic逐步回归分析的回归贡献率(决定系数)均低于10%,相对独立于老年人当前的人口学及社会、经济学状态。②对于绝大多数患有慢性病的老年人群来说,卫生服务调查的“患病”主要是主观感受,而不是临床意义上的“患病”,容易出现“天花板效应”。③卫生服务调查中“有无医务人员明确诊断”的慢性病取决于卫生服务的可及性和可获得性,没有医务人员明确诊断并不表示没有患病。半年前的“明确诊断”,如诊断时间、诊断名称、诊断机构等主要依靠记忆,因而老年人慢性病患病率在很大程度上取决于老年人(或家属)的记忆水平以及老年人接受医疗照顾的频率。研究还发现,在横断面调查中,两周患病率不是临床意义上的“患病”,老年人慢性病患病的诊断和治疗没有客观记录,缺乏体格检查的“金标准”。通过建立社区卫生服务信息系统和电子健康档案系统(EHR-s),可以实时从老年人的电子健康档案中提取相关数据,避免了老年人慢性病诊断的记忆偏倚。依据电子健康档案系统提供的信息,不仅老年人慢性病诊断和治疗有了客观依据,并且可以获取老年人社区卫生服务调查所能获得的全部信息,使社区卫生服务的提供者、卫生管理人员和政策制定者能够在任何需要的时候、围绕特定的研究目的进行实时分析(不局限于横断面调查),如卫生服务计划、卫生政策和卫生项目评价、健康状况评价、医疗需求分析等,从儿减少老年人社区卫生服务的研究费用、提高老年人社区卫生服务质量。结论:1.相对于老年居民比较高的社区卫生服务需求来说,长沙市老年居民社区卫生服务的利用率偏低。被调查的社区老年居民两周患病率、慢性病患病率均较高,潜在的卫生服务需求较大。虽然卫生服务可及性比较好,但就诊率、老年居民对社区卫生服务的知晓程度及社区卫生服务单项利用率均偏低。2.老年人健康状况评价和卫生服务需求和利用分析,不同于普通人群。由于年龄增长是导致老年人健康状况恶化的不可抗拒的因素,人口学及社会、经济学状态等对普通人群健康状况有影响的因素,对老年人群健康状况的影响力较小。相反,社区卫生服务知晓程度、是否患有慢性病和是否参加体育锻炼是影响被调查的社区老年居民个人躯体健康状况的主要因素。其中,经常参加体育锻炼对老年人保持身心健康起到很关键的作用,说明是否参加体育锻炼和社交活动,是反映老年人身心健康状况最重要的指标之一。3.老年人两周患病率和慢性病患病率不仅反映老年人的健康状况,也反映老年人卫生服务的可及性和可获得性。SF—36维度得分作为普适性健康指标,直接反映老年人当前的生存质量和主观感受,且没有记忆偏倚,在老年居民卫生服务需要调查中,应和两周患病率、疾病的严重程度及慢性病患病率指标一样,作为衡量老年人卫生服务需要量的一个指标。本研究发现,是否患有慢性病和是否参加体育锻炼,是影响老年人SF—36各维度得分最主要的两个决定性因素,证实了SF—36维度得分反映老年人健康状况的有效性(效度)。4.为了弥补横断面调查在老年人社区卫生服务调查的信息空档(如国家卫生服务调查每五年进行一次),连续性地获得老年人社区卫生服务记录,有必要进行城市老年人社区卫生服务基本数据集的研究。第二篇城市老年人社区卫生服务基本数据集研究目的:通过电子健康档案系统(Health Records System,EHR-s)从各种卫生服务记录中提取老年人健康和卫生服务信息,减少不必要入户调查,为实时采集和分析老年人社区卫生服务信息提供基本数据集和数据元标准,增强各级卫生行政部门的科学管理水平,合理配置卫生资源,有效地调控老年人社区卫生服务供求关系,提高卫生服务质量、降低医疗费用。方法:(1)在对调查对象获取有关数据的基础上,进一步从理论和实践两方面收集和整理国内外现有的老年人社区卫生服务数据集资料,通过模型的定义、数据集的评估和框架内容的确定形成数据实体,建立老年人社区卫生服务基本数据集框架。(2)数据元的标准化。(3)定义老年人社区卫生服务基本数据集框架的数据实体的数据内容。(4)建立老年人社区卫生服务基本数据集框架下的管理信息基本数据集。结果:(1)在国内外首次提出老年人社区卫生服务基本数据集框架(EHDSF)。EHDSF由参与者和语境的3×3交叉矩阵构成。EHDSF相关数据集的信息来源是居民健康档案。参与者可分为三个层次:个体、群体、机构;语境分别为管理、服务和评价。(2)结合《湖南省居民健康档案(肿瘤病人专项表)》,建立了城市老年人社区卫生服务数据元的标准化方法。(3)定义了个体管理信息16个基本数据集,分别是个体标识、人口与生物学特征、体格特征、劳动力特征、生活与行为特征、社会特征、教育特征、居住与环境特征、文化特征、社会保障特征、法律特征、健康状况、社会状况、经济状况、健康知识、角色关系。(4)定义了群体管理信息15个基本数据集、1个机构管理信息的基本数据集。结论:1.卫生行政机构可以在建立社会整体性老年医疗服务体系的同时,建立相应的信息网络,利用电子健康档案提供的信息,通过实时的数据分析提供老年人社区卫生服务的相关信息,并利用信息化手段带动和促进老年人社区卫生服务监督、考评和管理的现代化。2.数据集的内容和格式不统一,数据的定义和代码不相容,给数据交换和共享都造成了很大障碍,导致了数据的重复采集(重复检查),不仅阻碍这些数据的再次利用,也导致服务质量下降、医疗费用增加。3.老年人的所有健康记录都分散式地储存在电子健康记录系统中,本研究提出了EHDSF下的数据实体,涵盖了城市老年人社区卫生服务的各个方面,使现有的数据集被不同的使用者相互理解,对不同数据集中需要交换和共享的数据元逐步进行标准化。4.结合《湖南省居民健康档案(肿瘤病人专项表)》,建立了城市老年人社区卫生服务数据元的标准化方法。根据标准化数据集字段,有效地保证数据库的稳定性和可扩充性。5.本研究提出了城市老年人社区卫生服务管理信息的32个基本数据集,统一数据标准,减少资源浪费,为今后城市老年人社区卫生服务数据的一次采集、多次利用奠定了基础,具有一定的实用价值。更多还原

【Abstract】 Part One Research on the Health Status and Demands and Utilization of the Elderly Residents in Changsha for Community Health ServicesObjectives: We carried out an investigate on population structure, health status and the needs and wishes of the demand for community health services to community residents of the elderly living in Changsha, analyzed the impact factors of utilization of community services and understood the accessibility of the community health services under the guidance of the ’minimum data set of community health service for older people in urban’ project, one program of the national natural science foundation. To explore developmental direction and models on community health services which shift to the demand-oriented and to provide baseline data and policy basis for the elderly in Changsha. To provide field study data and statistical basis for establishing information and data sets of the urban elderly community health services.Methods: Subjects were selected by a multistage cluster sampling from five districts in Changsha city, Hunan Province in China. The baseline data of community-based was obtained by mean of a cross-section. (a) The health status and needs of community health services of the elderly in Changsha, including two-week prevalence, the prevalence of chronic disease, quality of life, health care; (b) Actual status of Utilization of community health services. (c) The wishes of demand of the elderly to community health services. The methods of descriptive analysis, comparative analysis, analysis of covariance and logistic regression analysis were used to process survey data.Results: We used indoor face-to-face interview and collected data of 630 elderly residents. The random sample came from 6 communities in Changsha city. There are 602 effective questionnaires and the efficiency rate was 95.6%. The sexual rate was 41.2% for male and 58.8% for female. The results indicated that the two-week prevalence was 52.0%, the two-week non- hospitalizing rate was 46.0%, and self- hospitalized rate of patients was 51.4%. There were 48.6% patients hadn’t taken any medical measure because of economy. The prevalence of chronic disease was 56.3% in sick elderly residents, while 100.8% in case load. There were 54.9% elderly residents suffer from two or three chronic diseases. 70.9% elderly could gain shortest distance of tenement from the health service center in one kilometer around their living-site. 8.3% residents gained medical health care knowledge from consultation doctors. The Comprehensive utilization rate of elderly community health service was 40.4%, and 11.0% elderly residents were uncared-for. The result of analysis of covariance indicated that there was close relation between chronic disease and scores of all dimension of SF-36. The univariate analysis indicated the main causes of limited elderly community health service were incomprehension of community health service, incomplete function of service station and absence of medical insurance. The multivariate analysis indicated earning and awareness degree with community health service were impact factors of community health service utilization in elderly people. There were some limitations in evaluation of the health status of the elderly residents and demands of health service, using two-week prevalence and prevalence of chronic disease: (a) In logistic step-wise regression analysis of two-week prevalence and prevalence of chronic disease, goodness-of-fit of logistic models (R~2) were less than 10%, and the results were disrelat ’suffering disease’ came from subjective psychology, not clinic meaning, which could easily cause ’ceiling effect’, (c) In the health service survey, ’having specific diagnosed chronic disease’ lied on possibility of health service accessibility and availability, diagnosed time, diagnosed name and diagnosed organization about half-past-year ’specific diagnosis’ lied on memory of elderly residents. The prevalence of chronic disease was affected by memory of elderly people and the utilization.Conclusions: (a) The utilization rate of health service of elderly residents in Changsha was lower than some other cities. The two-week prevalence and prevalence of chronic disease were relatively high, and there were great potential demands of health service in Changsha. Although, the possibility of health service accessibility and availability was good, the hospitalizing rate, awareness degree with community health service and utilization rate of health service was low. Comparing with high need and demand for community health services, the utilization rate of community health services of elderly residents living in Changsha was lower. (b) The result indicated the analysis of health status and utilization rate of health service in the elderly people was different to general population. Increasing age could deteriorate the health of people, while status of demography, sociology and economics could affect the health of elderly residents less than the general population. On the other hand, awareness degree with community health service, chronic disease and physical training were main impact factors of body health of elderly people. Physical training had pivotal effect on body and mental health of elderly residents, which indicated physical training and social doings were important indicators of mental health of elderly people. (c) The two-week prevalence and prevalence of chronic disease of the elderly residents reflected their health status, but also the possibility of accessibility and availability. As general-used health indicator, the scores of SF-36 dimensions directly reflected the quality of life and psychology. Scores of SF-36 dimensions should be an indicator of demands of health service, like two-week prevalence, graveness degree of disease and prevalence of chronic disease. The results indicated chronic disease and physical training were the most important impact factor of scores of SF-36 dimensions, which approved the validity of scores of SF-36 dimensions as indicator of health status of the elderly residents. (d) To make up the information blank of cross-sectional study of community health service of the elderly residents, and obtain continuous data about community health service of the elderly resident record, it was necessarily to analyze the basic data set of community health service on the elderly. In cross-sectional study, two-week prevalence dose not mean the prevalence of clinic diagnosed disease, and there weren’t diagnosis and treatment records and criterions. Part Two The Basic Data Set of Community Health Service on the Elderly in UrbanObjectives: To enhance the level of scientific management of all levels health administrative departments and allocate rationally health resources and accommodate effectively the relationship between supply and demand of the elderly community health services, improve services quality and reduce medical costs. To gather the elderly health and health services information from a variety of health services records by mean of Electronic Health Records System and reduce unnecessary surveys among households and provide basic data sets and data collection standards for real-time collection and analysis of data of elderly community health services and information.Methods: (a) The existing data sets of elderly community health service were collected and cleaned up to form data entity and to establish the framework of data sets of the elderly community health services by defining model and evaluating data sets and determining the content of framework. (b) The data sets were standardized. (c) Thebasic data sets of administrant information under the framework of the data sets of the elderly community health services were established.Results: (a) The elderly community health service data sets framework (EHDSF) was raised for the first time. The framework was composed of a 3×3 crossed matrix including participants and context. The source of information of related data sets among framework data sets was the recodes of residents’ health. Participants were divided into three levels: individuals, populations and organizations. The context was divided into management, services and evaluation. (b) We combined the ’ The recodes of residents’ health in Hunan (tumor patients special table),’ and established standardized methods of data element of the elderly community health services in urban. (c) Sixteen basic data sets of individual managementing information were defined, which were respectively individual identification, population and biological characteristics, physical characteristics, labor characteristics, living and behavioral characteristics, social characteristics, educational characteristics, living and the environmental characteristics, cultural characteristics, social security characteristics, legal characteristics, health status, social status, economic status, health knowledge and role characteristics. (d) Fifteen basic data sets of population management information and one basic data set of administrant information of organization were defined.Conclusions: (a) The authorities of health and administration may establish a corresponding information networks when a comprehensive social health service system was established for elderly and the information of electronic health recodes was utilized to analyze and provide related information of community health services on the elderly by mean of analyzing real-time data and utilizing information-based technology to drive and promote the modernization of surveillance, evaluation and management of the elderly community health services. (b) Disunity of the content and format of data sets and incompatibility of definitions and codes of data had caused large obstacles for the exchange and sharing of data and resulted in repetitive of data collection (repetitive inspection), which not only hindered utilization of these data again, moreover induced a decline in service quality and a increase in medical costs. (c)All health records of the elderly were saved dispersedly in electronic health records system. Our study had put forward a data entity under EHDSF, which covered the elderly community health services in all aspects in urban, so that existing data sets could be understood one another by different users. Stepwise standardization had been carried out for different data sets which need to exchange and share data element. (d) A standardized method of data element in urban elderly community health services had been established after combining ’The recodes of residents’ health in Hunan (tumor patient special table)’. At the same time the stability and scalability of database had been guaranteed by means of fields of standardized data sets. (e) Our study raised 32 basic data sets of the urban elderly administrant information of community health services, unified data standard, reduced the waste of resources, laid the foundation for one-off data collection of the urban elderly community health services and had a better practical value.更多还原