研究目的

本研究旨在全面分析北京市常住居民跨区住院的现状及影响因素的动态变化，并基于安德森卫生服务利用模型深入挖掘，分析不同因素对患者跨区住院选择的效应，并为优化医疗资源配置与引导居民合理就医提供科学依据。

研究方法

本研究使用横断面调查与回顾性数据分析相结合的方法，基于2016—2023年北京市1800余万人次的出院病人调查表和医疗机构年报表数据（整理为病案首页数据库），以及2018年与2023年全国卫生服务调查北京市家庭健康调查表数据（整理为服务调查数据库），以北京地区参与全国卫生服务调查的3068名住院患者为研究对象。

被解释变量为患者跨区住院选择情况，病案首页数据库中，患者住院的医院所属行政区域与患者现住址或联系地址不一致时视为跨区住院；服务调查数据库中，以患者回答“您本次住院是在：1.本县（市、区），2.本市外县（市、区），3.本省外市，4.外省”，筛选并判断患者该次住院是在“区内住院”或是“跨区住院”；根据文献综述与数据可获得性，纳入倾向特征、使能资源以及需求因素3个维度41个解释变量。

使用描述性分析、Pearson卡方检验与t检验对关键指标进行描述性分析与单因素分析，使用多因素Logistic回归、稳健性检验、异质性分析进行多因素分析。

研究结果

1. 2016-2023年北京地区常住居民总体住院量呈显著波动但总体增长的趋势，年均跨区住院率为42.32%；东城区（57.21%）、丰台区（55.21%）、海淀区（52.05%）跨区住院率最高，使用交通距离校正后，各郊区跨区住院率大幅降低，但通州区（27.39%）、延庆区（26.72%）、顺义区（26.67%）以及密云区（25.93%）常住居民的跨区住院率仍维持在较高水平；2023年数据显示，跨区住院患者主要流向海淀区（15106人次）、西城区（18902人次）和丰台区（9968人次）；跨区住院费用始终高于区内住院费用，年均复合增长率为2.05%；与二级医疗机构相比，跨区至三级医疗机构住院患者占比长期高于80%；与常见病患者相比，2023年多个行政区的疑难病患者跨区住院占比较2018年有所增加；且医疗机构整体服务评价均有提升，患者满意度评价持续向好。

2. 单因素分析结果显示，与2018年相比，倾向特征中，高龄（≥60岁）、高学历（大专及以上）及离退休人群跨区住院比例增加，增幅范围为4.39%至11.54%；未婚群体的跨区住院比例下降且统计差异消失，同时健康风险因素、职业类型的跨区住院差异均弱化，而教育水平与就业状态的跨区选择差异进一步扩大；使能因素方面，跨区患者收入优势持续显著（P<0.001），高收入组跨区比例跃升（13.46%增加至21.46%），且商保参保者跨区住院倾向增强（2023年P=0.002），2023年邻近更高等级医疗机构者跨区住院率更高（P=0.015），选择区属以上机构住院者跨区比例突出（2023达21.13%）；需求因素角度，手术患者跨区住院比例持续显著高于非手术患者（2018年P<0.001；2023年P=0.003），且2023年新入院患者跨区率（21.79%）显著高于再入院者（11.54%，P=0.013）；主观需求层面，2018年因孕等“其他”原因住院者跨区比例（25.71%）显著高于疾病住院者（P=0.003），但2023年此差异消失（P=0.314）。

3. 影响北京市常住居民跨区住院选择的因素包括年龄、性别、医保类型、疾病复杂程度、医疗机构等级、医疗机构类型、婚姻状态、家庭医生签约方式、是否有健康风险因素、家庭年度总收入、家庭年度医疗支出、离家最近医疗机构距离、到最近医疗机构所用时间、入院等候时间、是否需要手术以及住院原因等。

研究结论与建议

1. 本研究首次对北京市常住居民跨区住院情况进行分析，结果发现，北京市跨区住院率一直处在较高水平，对引导患者合理就医、落实分级诊疗制度提出挑战。

2. 北京常住居民的跨区住院选择受多因素影响：病案首页回归分析显示，女性、高龄、城镇职工/居民医保或商业医保参保者、伴有合并症或并发症的患者更倾向选择区内住院，且偏好三级综合医疗机构；服务调查则进一步揭示婚姻状态、家庭年收入、离家最近医疗机构距离、是否需要手术、入院等候时间等变量对跨区行为具有显著影响，且这些因素的作用强度随时间或模型检验分析呈现动态变化。

3. 本研究提出，北京市应进一步优化医疗资源配置，缓解区域不平衡；强化健康干预，降低住院需求；针对性支持脆弱群体，减少健康不平等；完善数据监测与政策动态评估机制；引导患者合理就医，构建合理就医秩序。

Objective

This study aims to comprehensively analyze the current situation of cross-district hospitalization of permanent residents in Beijing and the trends of influencing factors over time. Based on Anderson's health service utilization model, it examines the effects of different factors on patients' choices of cross-district hospitalization, aiming to provide a scientific basis for optimizing healthcare resource allocation and guiding residents to seek medical treatment rationally.

Methods

This study combines cross-sectional surveys and retrospective data analysis. Data were sourced from: (1) over 18 million inpatient medical record front sheets and annual reports of healthcare institutions in Beijing (2016–2023), compiled into a case-based inpatient database; and (2) the Chinese National Health Services Survey in Beijing (2018 and 2023), compiled into a service survey database. The study population comprised 3,068 hospitalized patients.

The explanatory variable was the patients' choice of hospitalization across districts, which was regarded as cross-district hospitalization in the case homepage database by the administrative region of the hospital where the patient was hospitalized if it did not coincide with the patient's current address or contact address; and in the service survey database by the patient's answer to the question, “You were hospitalized this time in: 1. this county (city or district), 2. outside the county (city or district) of this city, 3. outside the city of this province, and 4. in a foreign province. To determine whether a patient's current hospitalization was “within the district” or “across districts”, 41 explanatory variables in three dimensions, predisposing characteristics, enabling resources and need, were included based on the literature review and data availability.

Descriptive analysis, Pearson chi-square test, and t-test were used for descriptive and univariate analyses of the key indicators, and multivariate analyses were conducted using multivariate logistic regression, robustness testing, and heterogeneity analysis.

Results

1. Overall trends: From 2016 to 2023, the hospitalization volume of permanent residents in Beijing exhibited significant fluctuations but an overall upward trend, with an average annual cross-district hospitalization rate of 42.32%. Districts with the highest rates were Dongcheng (57.21%), Fengtai (55.21%), and Haidian (52.05%). After adjusting for transportation distance, the cross-district rates of suburban districts decreased substantially, except for Tongzhou (27.39%), Yanqing (26.72%), Shunyi (26.67%), and Miyun (25.93%), where rates remained high. In 2023, patients primarily flowed to Haidian (15,106 cases), Xicheng (18,902 cases), and Fengtai (9,968 cases). Cross-district hospitalization costs grew at a compound annual rate of 2.05%, consistently exceeding in-district costs. Over 80% of patients sought care at tertiary institutions (vs. secondary), and the proportion of patients with complex diseases hospitalized across districts increased in 2023 compared to 2018. Patient satisfaction with healthcare services improved overall.

2. The results of univariate analysis showed that compared with 2018, among the propensity characteristics, the proportion of cross-district hospitalization increased in the senior age (≥60 years), high education (college and above) and retired groups, with a range of 4.39% to 11.54%; the proportion of cross-district hospitalization in the unmarried group declined and the statistical difference disappeared, while the differences in cross-district hospitalization of health risk factors and occupational types were weakened, and the differences in the educational level and employment The differences in cross-district selection by education level and employment status further widened; in terms of enabling factors, the income advantage of cross-district patients continued to be significant (P<0.001), the proportion of cross-district jumped in the high-income group (13.46% to 21.46%) and the propensity for cross-district hospitalization increased for those with commercial insurance enrollees (P=0.002 in 2023), and those who were close to a higher level of healthcare had a higher cross-district rate of hospitalization in 2023 (P=0.015), and those choosing district had a higher rate of hospitalization (P=0.015). 0.015), and those who chose to be hospitalized in institutions above the district had a prominent rate of cross-district hospitalization (up to 21.13% in 2023); from the perspective of demand factors, the rate of cross-district hospitalization continued to be significantly higher for surgical patients than for non-surgical patients (P<0.001 in 2018; P=0.003 in 2023) and the rate of cross-district hospitalization was significantly higher among newly-admitted patients (21.79%) than among those who were re-admitted to the hospital (P=0.002, P=0.001 in 2023). 11.54%, P=0.013); at the subjective need level, the proportion of those hospitalized for “other” reasons, such as pregnancy, who crossed districts was significantly higher (25.71%) than those hospitalized for illness in 2018 (P=0.003), but this difference disappeared in 2023 (P=0.314).

3. Factors affecting the choice of hospitalization across districts for Beijing permanent residents include age, gender, type of health insurance, complexity of disease, level of medical institution, type of medical institution, marital status, family doctor contracting method, presence of health risk factors, total annual household income, annual household medical expenditure, distance to the nearest medical institution from home, time taken to reach the nearest medical institution, waiting time to be admitted to the hospital, the need for surgery, and reasons for hospitalization.

Conclusions and Recommendations

1. This study provides the first comprehensive analysis of cross-district hospitalization among permanent residents in Beijing, revealing a persistently high inter-district hospitalization rate that challenges the implementation of hierarchical diagnosis and treatment.

2. The choice of inter-district hospitalization among Beijing residents is influenced by multiple factors: regression analysis shows that women, elderly, urban workers/residents with health insurance or commercial health insurance, and patients with comorbidities or complications are more likely to choose in-district hospitalization and prefer tertiary comprehensive medical institutions; the service survey further reveals that variables such as marital status, annual household income, distance to the nearest medical institution, the need for surgery, and waiting time have a significant impact on inter-district behavior, and the strength of the effect of these factors dynamically increases with time or model test analysis.

3. This study proposes that Beijing should further optimize the allocation of healthcare resources to alleviate regional imbalances; strengthen health interventions to reduce hospitalization demand; target support for vulnerable groups to reduce health inequalities; improve the mechanism of data monitoring and dynamic evaluation of policies; and guide patients to rationally seek medical care and build a reasonable order of medical care.