基于中国家庭追踪调查的居民主观认知、收入变化与就医点选择转移的关联

Associations of subjective perceptions and income change with transitions in usual source of care among Chinese residents：A study based on China Family Panel Studies

摘要

目的：基于中国家庭追踪调查（China Family Panel Studies，CFPS）数据，描述中国成年人通常就医点结构变化和主观认知变化，并分析主观认知和收入变化与就医点选择转移的关联。方法：本研究为回顾性纵向观察研究，使用 CFPS 2012、2014、2016、2018、2020、2022年六轮调查的成年人数据。先描述3类通常就医点（基层、医院、诊所）构成的时间趋势，以及居民对医疗机构主观认知与居民相对收入变化的时间趋势；再构建相邻两轮调查人-期样本，在＂基线为基层＂和＂基线为非基层＂两组中分别分析基层流出与流入。核心解释变量为上一轮调查满意度、医疗水平评价及相对收入变化情况；其中收入变化变量根据同一轮调查的同一省份样本内相对收入组的变化构造。描述分析采用横截面权重；主回归为未加权二分类 Logistic 模型，并按个体进行聚类稳健标准误估计，报告优势比（odds ratio，OR）、 95 ％置信区间（confidence interval，CI）和 P 值。结果：六轮调查数据合并后共纳入 135986条记录、34010名个体。2012-2022年通常选择基层医疗机构就医的居民占比由 43.49% 降至 30.34% ，医院占比由 34.06% 升至 46.81% ；其中基层占比在 2012—2018 年下降更快（43.49% 降至 33.72%），2018年后继续下降但降幅趋缓（33.72% 降至 30.34%）。在相邻两轮调查中，基层流出比例由 35.47% 升至 45.22% ，基层流入比例由30.09％降至19.60％，基层就医流出增加和流入减少并行。2012—2022年，居民对基层、医院、诊所三类机构主观认知持续提升，但基层与医院的相对差距在医疗水平方面有所扩大，基层相对诊所的主观认知从微弱领先转为明显落后。相对收人不变的居民占比由 50.64% 升至 60.33% 。多因素回归显示，对基层医疗服务的满意度每提高 1分，基层流出的优势比下降 $7.5\mathrm{\%}\text{ }(\mathit{O}\mathit{R}=0.925,\text{ }\mathit{P}<0.001)\text{ }$ ；对非基层医疗机构医疗水平的评价每提高1分，基层流人的优势比下降 $5.3\mathrm{\%}\text{ }(\mathit{O}\mathit{R}=0.947,\text{ }\mathit{P}<0.001)\text{ }$ 。与相对收入组不变者相比，相对收入组上移者，特别是从低收入组升至高收入组者，表现为更高的基层流出优势比和更低的基层流入优势比（流出 OR=1.166 ；流入 OR=0.840）；相对收人组下移者，特别是从高收入组降至低收入组者，则表现为更低的基层流出优势比和更高的基层流入优势比（流出 OR=0.785 ；流入 OR=1.371）。结论：我国基层就医利用持续下降，且基层流出增加和基层流入减少同时存在。居民主观认知在基层流出与流入中的关注点并不相同：前者更多与满意度相关，后者更多与医疗水平判断相关。相对收入组上移人群对基层的利用倾向相对较弱。分级诊疗政策应同步关注＂导人基层＂和＂留在基层＂，以连续照护体验稳定存量，以能力建设和制度安排吸引增量，并通过支付激励提升基层吸引力。

Abstract

Objective：Using the China Family Panel Studies（CFPS，2012-2022），this study aimed to characterize changes in the distribution of usual sources of care and in subjective perceptions among Chinese adults，and to examine the associations of subjective perceptions and income change with next- wave transitions in usual source of care. Methods：This was a retrospective longitudinal observational study based on adult CFPS data from 2012，2014，2016，2018，2020，and 2022.We first described temporal trends in three types of usual source of care（primary care，hospitals，and clinics），as well as trends in residents＇subjective perceptions of healthcare providers，and in relative income change.We then constructed person-period samples from adjacent survey waves and analyzed two transition processes separately：outflow from primary care among baseline primary care users and inflow to primary care among baseline non-primary care users.Key predictors were prior-wave satisfaction，perceived medical compe- tence，and relative income change；the income-change variable was defined based on changes in relative income group within the same wave and same province sample.Descriptive analyses applied cross- sectional weights；the main regressions were unweighted binary Logistic models with individual-level cluster-robust standard errors，reporting odds ratios (OR),95% confidence intervals（95%CI），and P va-lues. Results：The pooled sample comprised 135986 observations from 34010 individuals.From 2012 to 2022，the proportion using primary care as the usual source of care declined from 43.49％to 30.34％， whereas the hospital share rose from 34.06％to 46.81％.The decline in primary care was steeper during 2012-2018（43.49％to 33.72％）and persisted at a slower pace thereafter（33.72％to 30.34％）. Across adjacent survey waves，primary care outflow increased from 35.47% to 45.22% ，while primary care inflow decreased from 30.09% to 19.60% ，indicating simultaneous increases in exits and decreases in entries.Subjective perceptions improved for all three provider types over time；however，the relative gap between primary care and hospitals widened on perceived medical competence，and primary care shifted from a slight advantage over clinics to a clear disadvantage in composite subjective perceptions. The proportion of residents with unchanged relative income group rose from 50.64％to 60.33％.In mul- tivariable models，each one-unit increase in satisfaction with primary care was associated with 7.5％lower odds of leaving primary care（OR=0.925,P<0.001）.In contrast，each one-unit increase in perceived medical competence of non-primary care providers was associated with 5.3％lower odds of moving into primary care $(\mathit{O}\mathit{R}=0.947,\mathit{P}<0.001)$.Compared with stable relative income group，upward relative income-group mobility，particularly low-to-high movement，was associated with higher odds of outflow from primary care and lower odds of inflow to primary care（outflow OR=1.166 ；inflow OR=0.840）， whereas downward relative income-group mobility，especially high-to-low movement，showed the opposite pattern（outflow OR=0.785 ；inflow OR=1.371）. Conclusion：Primary care utilization in China con- tinued to decline，with increased outflow from primary care and reduced inflow to primary care occurring simultaneously.Residents＇subjective perceptions were associated with different considerations in reten- tion in versus movement into primary care：the former was more closely related to satisfaction，whereas the latter was more closely related to perceived medical competence.People with upward relative income- group mobility showed a lower inclination to use primary care.Hierarchical care policy should address both entry into and retention in primary care by strengthening continuity of care，reinforcing service capa- bility and institutional design，and aligning payment incentives.

关键词

初级卫生保健 / 通常就医点 / 病人接受卫生保健的程度 / 病人满意度 / 收入 / 纵向研究

Key words

Primary health care / Usual source of care / Patient acceptance of health care / Patient satisfaction / Income / Longitudinal studies

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基金资助

国家社会科学基金重大项目(22＆ZD143)