背景

随着社会经济发展、城镇化进程加快和人口老龄化以及行为危险因素流行影响，慢性病如心脑血管疾病、肿瘤、糖尿病和慢性呼吸系统疾病以及精神心理健康问题等慢性病流行呈不断上升趋势。人口老龄化和慢性病增加也是人群共病流行的主要推动因素。慢性病和共病不仅影响个人的健康和生活质量，也会增加医疗保健成本和影响经济发展。国内外学者开发了医疗保健生态模型用于评估以慢性病为主的人群患病状况以及前往不同医疗机构就诊的分布，但是缺乏慢性病和共病一起进行评估研究以及相应服务模式和政策的探讨。

研究目的

应用医疗保健生态学模型评估调查人群的多层次卫生服务利用模式，描述慢性病共病现状及其特征分布，并探讨慢性病患者卫生服务利用现状，分析不同特征人群卫生服务利用的差异，为慢性病共病管理及医疗卫生资源配置相关政策制定提供证据基础。

研究方法

基于对以往医疗保健生态学模型的系统概况性研究，设计反映医疗保健生态框架的相应调查问卷，了解不同特征人群慢性病共病和卫生服务利用情况。于2023年7月至9月期间在北京市房山区和江西省婺源县开展横断面调查。通过多阶段整群抽样选取两地20岁及以上的常住人口6004名作为调查对象，收集其人口社会学信息、健康与疾病状况、卫生服务利用情况；运用SPSS软件采用多因素Logistic 回归分析慢性病共病的相关因素及不同特征人群卫生服务利用的差异。

研究结果

（1）房山和婺源地区整体医疗保健生态图显示平均每月每1000人中约有382人报告有症状，162人有就诊行为，62人自行用药，47人前往三级医院门诊就诊，25人前往中医院就诊，10人住院，5人急诊就诊，4人接受手术治疗，1人接受远程诊疗。北京房山地区的调查对象在报告症状、医疗机构就诊、自行用药和住院层级方面的人数占比高于江西婺源地区。

（2）有超过31.9%的20岁及以上人群为共病患者。自报慢性病患病率排在前4位的疾病为高血压、糖尿病、颈椎病、心脏病。以高血压（49.5%，947/1915）、糖尿病（20.1%，385/1915）、颈椎病（18.7%，359/1915）、心脏病（14.1%，270/1915）为核心疾病的慢性病共病患病率在人群中占比高。房山地区的高血压、糖尿病、心脏病、肝脏疾病、脑卒中、胃病、哮喘、精神心理疾病的共病率高于婺源地区。年龄、受教育程度、工作类型、医疗保障类型与慢性病共病发生显著相关。

（3）与单病人群相比，患有2种慢性病、3种慢性病和≥4种慢性病的共病患者报告症状分别是其1.61倍（95%CI: 1.37-1.90）、2.04倍（95%CI: 1.66-2.52）和3.52倍（95%CI: 2.81-4.42）；患有2种慢性病、3种慢性病和≥4种慢性病的共病患者前往医疗机构就诊分别是单病患者的1.73倍（95%CI: 1.41-2.12）、2.18倍（95%CI: 1.70-2.80）、3.01倍（95%CI: 2.34-3.87），其住院分别是1.52倍（95%CI: 1.21~1.90）、2.06倍（95%CI: 1.58~2.69）和3.90倍（95%CI: 3.00-5.07）。单病患者与患2种、3种慢性病患者相比在自行用药上无显著差异。非农业户口人群前往三级医院和综合医院门诊分别是农业户口人群的1.86倍（95%CI: 1.30-2.65）、1.42倍（95%CI: 1.06-1.89）。城镇职工医保人群前往三级医院和综合医院门诊分别是城乡居民医保人群的2.10倍（95%CI: 1.44-3.06）、1.54倍（95%CI: 1.13-2.10）。

研究结论

（1）本研究利用医疗保健生态学模型反映了中国人口多样化的医疗保健需求和使用情况。研究结果表明，在前往医院就诊的人群之外，可能还有大量的健康需求未得到满足。这反映了潜在的未得到满足的医疗需求，并凸显了医疗系统所面临的挑战，即初级医疗系统相对薄弱，而三级医院负担过重。非农业户口人群和城镇职工医保人群更多地前往了三级医院和综合医院。亟需进一步提高基层医疗机构对慢性病的综合诊治能力，更好地满足患者的健康需求。同时，研究也发现了远程医疗的使用为加强医疗保健系统提供了新的机遇。

（2）在14种纳入分析的慢性病中，被调查人群中的自报患病率居于前4位慢性病分别为高血压、糖尿病、颈椎病、心脏病。高血压相关的共病率最高。房山地区调查对象的共病率高于婺源地区，年龄、受教育程度、工作类型、医疗保障类型是共病发生的相关因素。不同地区居民医疗服务利用存在差异，提示需针对不同健康需求，因地制宜，进一步完善以健康为中心的全过程健康照护管理。

（3）调查人群共病人群医疗服务利用率均高于非共病人群，共病与各层级医疗服务利用增加（报告症状、医疗机构就诊、自行用药、住院以及对手术治疗的使用）呈正相关。从不同级别和类型的医疗机构来看，共病人群在基层医疗机构、三级医院、综合医院就诊显著增加。随着人口老龄化及疾病谱的变化，慢性病共病与各层级医疗服务利用增加相关，其中以门诊住院较为突出。政府及有关部门需要积极应对共病对卫生体系带来新需求和新挑战，进一步完善医疗保健生态体系，强化基层医疗机构的能力，形成各层级医疗机构的共病整合照护模式。

Background:

The prevalence of chronic diseases such as cardiovascular and cerebrovascular diseases, tumors, diabetes mellitus and chronic respiratory diseases, as well as mental and psychosocial health problems, is on the rise as a result of socio-economic development, the acceleration of urbanization and the ageing of the population, as well as the prevalence of behavioral risk factors. Population ageing and the increase in chronic diseases are also major drivers of the prevalence of multimorbidity in populations. Chronic diseases and multimorbidity not only affect the health and quality of life of individuals, but also increase the cost of health care and affect economic development. Domestic and international scholars have developed healthcare ecological models to assess the prevalence of chronic diseases and the distribution of visits to different healthcare institutions, but there is a lack of research on the assessment of chronic diseases and co-morbidities together, as well as the exploration of corresponding service models and policies.

Objective：

This study applied the ecology of medical care model to assess the health service utilization patterns of residents in Fangshan District, Beijing and Wuyuan County, Jiangxi Province, China. The study aims to (1) describe the epidemiological pattern of multimorbidity, (2) the describe the status of health service utilization among residents in selected settings, (3) analyze the differences in the utilization of health services among population with different characteristics. The study findings will provide an evidence base for the management of multimorbidity and shed lights on how to better allocate healthcare resources for individuals with diverse health needs.

Methods：

This study is built on a scoping review of previous studies that utilized the ecology of medical care model to understand the healthcare service utilization in various settings. Based on the review, an updated healthcare ecology framework hierarchy was developed and a questionnaire was then developed to reflect each level of the ecology framework. A cross-sectional survey was carried out between July and September 2023 in Fangshan District, Beijing and Wuyuan County, Jiangxi Province. Residents, aged 20 years old and above and lived in these two settings for at least 6 months over the past 12 months were eligible and recruited in the survey. A total of 6004 participants completed the survey with data collection on their socio-demographic information, health and disease status, and health service utilization. Descriptive analysis was performed on the prevalence of multimorbidity among participants and multivariate logistic regression was used to analyze factors associated with health service utilization across population. The association between multimorbidity and healthcare service utilization was further analyzed by multivariate logistic regression. All analysis was performed by using SPSS software.

Results：

(1) Among all survey respondents, 56.4% were female, the average age was 50.4 ±14.7 years old, 41.2% of the people in Wuyuan area had primary school education or below, and the average level of education in Fangshan was obviously higher, with the proportion of university education or above reaching 29.9%. Among all surveyed respondents, the healthcare utilization was reported as number per 1,000 people per month. An average of about 382 per 1,000 people per month reported symptoms, 162 had medical consultations, 62 used their own medication, 47 had outpatient clinic visits at tertiary hospitals, 25 went to traditional Chinese medicine hospitals, ten were hospitalized, five had emergency department visits, four underwent surgical procedures, and one received tele-diagnosis and treatment. Participants in Beijing Fangshan had significantly higher proportion in reported symptoms, medical institution visits, self-medication and hospitalization tiers than participants from Jiangxi Wuyuan area.

(2) More than 31.9% of the participants self-reported suffered from two or more chronic diseases, considered as multimorbidity. The prevalence of multimorbidity was higher among females, the elderly than males and younger counterparts. Hypertension, diabetes, cervical spondylosis, heart disease were top four diseases that had the highest prevalence rate based on the self-report information. The co-morbidity rate of chronic diseases with hypertension (49.5%, 947/1915), diabetes mellitus (20.1%, 385/1915), cervical spondylosis (18.7%, 359/1915), and heart disease (14.1%, 270/1915) as the core diseases accounted for a high proportion in the population. The co-morbidity rates of hypertension, diabetes, heart disease, liver disease, stroke, stomach disease, asthma, and psychosomatic disease were higher in Fangshan than in Wuyuan. Age, education, type of work, and type of health care coverage were significantly associated with the prevalence of multimorbidity.

(3) Compared with individuals who self-reported had one disease, Co-morbid patients with 2 chronic diseases, 3 chronic diseases and ≥4 chronic diseases were 1.61 (95% CI: 1.37-1.90), 2.04 (95% CI: 1.66-2.52) and 3.52 (95% CI: 2.81-4.42) times more likely to report symptoms; Co-morbid patients with 2 chronic diseases, 3 chronic diseases, and ≥4 chronic diseases were 1.73 times (95% CI: 1.41-2.12), 2.18 times (95% CI: 1.70-2.80), and 3.01 times (95% CI: 2.34-3.87) more likely than patients with a single disease to visit a healthcare facility, and their hospitalizations were 1.52 times (95% CI. 1.21-1.90), 2.06 times (95% CI: 1.58-2.69), and 3.90 times (95% CI: 3.00-5.07), respectively, for hospitalization. There was no significant difference in self-administration of medication in patients with a single disease compared to those with 2 or 3 chronic diseases. Outpatient visits to tertiary and general hospitals were 1.86 times (95% CI: 1.30-2.65) and 1.42 times (95% CI: 1.06-1.89) higher for non-agricultural hukou than for agricultural hukou, respectively. Outpatient visits to tertiary and general hospitals were 2.10 times (95% CI: 1.44-3.06) and 1.54 times (95% CI: 1.13-2.10) more common among urban workers than among urban and rural residents, respectively.

Conclusion：

(1) This study utilized the ecology of health care model and reflects the diverse healthcare needs and utilization among population in China. The findings suggest that there may be a large number of unmet health needs among population beyond those who had seek care from hospitals. This reflects the potential unmet health needs and highlights the challenge faced by the healthcare system with relatively weak primary healthcare system and the over-burden across tertiary hospitals. The non-agricultural household population and the urban workers' health insurance population travelled more to tertiary and general hospitals. Therefore, it is great needed to further improve the comprehensive diagnosis and treatment capacity of primary healthcare institutions for chronic diseases, and to better meet the health needs of patients. The reported utilization of telemedicine offers new opportunity for healthcare system strengthening.

(2) Among the 14 chronic diseases that involved in the analysis, the top 4 chronic diseases with the highest prevalence rates were hypertension, diabetes, cervical spondylosis, and heart disease. The prevalence of hypertension-related multimorbidity was the highest. About one third of participants suffered from multimorbidity with a higher prevalence among participants in Fangshan, Beijing, than in Wuyuan, Jiangxi. Age, education level, type of work, and type of medical insurance were the influencing factors for the occurrence of chronic disease co-morbidities. Differences in the use of healthcare services between different regions and populations suggest the need to further improve health-centered, whole-course health-care management in response to different health needs and in accordance with local conditions.

(3) The utilization rate of medical services for all co-morbid groups in the survey population was higher than that of non-co-morbid groups, Multimorbidities were positively associated with increased utilization of healthcare services at all levels (reporting of symptoms, visits to healthcare facilities, self-administration of medication, hospitalization, and use of surgical treatments). Looking at the different levels and types of healthcare facilities, the multi-morbid population had significantly more visits to primary care, tertiary care, and general hospitals. The government and relevant authorities need to actively respond the new demands and challenges posed by multimorbidity to the health system, further improve the healthcare ecosystem, strengthen the capacity of primary healthcare institutions, and promote an integrated care model for multimorbidity management at all levels of care.