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北京大学学报（医学版） ›› 2025, Vol. 57 ›› Issue (4): 753-758. doi: 10.19723/j.issn.1671-167X.2025.04.020

• 论著 • 上一篇    下一篇

心力衰竭患者门诊服务利用对住院率的影响及其阈值效应——以浙江省城镇职工患者为例

章湖洋1, 景日泽2, 王金喜3, 方海4,5,*()   

  1. 1. 北京大学国家发展研究院, 北京 100871
    2. 中国人民大学公共管理学院, 北京 100872
    3. 上海崧胜商务咨询有限公司, 上海 201913
    4. 北京大学中国卫生发展研究中心, 北京 100191
    5. 北京大学医学部中国疾病预防控制中心疫苗经济学联合研究中心, 北京 100191
  • 收稿日期:2022-10-10 出版日期:2025-08-18 发布日期:2025-08-02
  • 通讯作者: 方海
  • 基金资助:
    国家自然科学基金(71774006)

Impact of outpatient services utilization of heart failure patients on hospitalization rate and its threshold effect: Taking patients with Urban Employee Basic Medical Insurance in Zhejiang Province as an example

Huyang ZHANG1, Rize JING2, Jinxi WANG3, Hai FANG4,5,*()   

  1. 1. National School of Development, Peking University, Beijing 100871, China
    2. School of Public Administration and Policy, Renmin University of China, Beijing 100872, China
    3. Shanghai Songsheng Business Consulting Co. Ltd, Shanghai 201913, China
    4. China Center for Health Development Studies, Peking University, Beijing 100191, China
    5. Peking University Health Science Center-Chinese Center for Disease Control and Prevention Joint Center for Vaccine Econo-mics, Beijing 100191, China
  • Received:2022-10-10 Online:2025-08-18 Published:2025-08-02
  • Contact: Hai FANG
  • Supported by:
    the National Natural Science Foundation of China(71774006)

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摘要：

目的: 分析心力衰竭患者门诊服务利用对住院率的影响及其阈值效应，为制定心力衰竭患者门诊医疗保险报销政策提供依据。方法: 采用分层随机抽样方法，提取2013—2017年浙江省城镇职工基本医疗保险心力衰竭患者个体报销数据，运用面板固定效应logit回归模型和阈值效应模型，分析上年年门诊服务利用对当年住院率的影响及其阈值效应。年门诊服务利用指标包括年门诊次数、年门诊总费用、年门诊药费以及年门诊政策范围内自付费用。住院率指标包括年住院率、30 d内再住院率和90 d内再住院率。结果: (1) 上年年门诊服务利用的增加会引起当年年住院率的降低，但对30 d内再住院率和90 d内再住院率无影响；(2)上年年门诊服务利用对当年年住院率存在阈值效应。当上年年门诊次数小于或等于阈值(12次)时，随着上年年门诊次数的增加，当年年住院率下降且具有统计学意义，当上年年门诊次数高于阈值(12次)时，其回归系数不显著。相应的，上年年门诊总费用和年门诊政策范围内自付费用的阈值分别为3 342.8元、736.9元。结论: 心力衰竭患者门诊服务利用对住院率存在阈值效应，提示医保政策制定者在设计心力衰竭患者的门诊报销政策时，应考虑到年门诊总费用等对年住院率的阈值，这有助于优化医疗资源的利用并同时减轻患者和医保基金的负担。

关键词: 城镇职工基本医疗保险, 心力衰竭, 门诊服务利用, 住院率, 阈值效应

Abstract:

Objective: To examine the impact of outpatient service utilization on hospitalization rates in patients with heart failure, with a focus on identifying the threshold effect, and to provide evidence to support the design of outpatient medical insurance reimbursement policies for heart failure patients. Methods: Using a stratified random sampling method, individual reimbursement data of heart failure patients covered by Urban Employee Basic Medical Insurance in Zhejiang Province from year 2013 to 2017 were extracted. A panel fixed-effects logit regression model and a threshold effect model were applied to analyze the impact of annual outpatient service utilization in the previous year on the hospitalization rate in the current year and to identify the threshold effect. The annual outpatient service utilization indicators included the annual outpatient visits, annual outpatient expenses, annual outpatient drug expenses, and annual outpatient self-expenses within the policy. Hospitalization rate indicators comprised the annual hospitalization rate, rehospitalization rate within 30 days, and rehospitalization rate within 90 days. Results: (1) The study found that an increase in prior-year annual outpatient service utilization led to a decrease in the current-year annual hospitalization rate. However, the effects on the rehospitalization rate within 30 days and rehospitalization rate within 90 days were not statistically significant; (2) The thre-shold effect of prior-year annual outpatient service utilization on the current-year annual hospitalization rate was also identified. When the prior-year annual outpatient visits were less than or equal to the threshold (12 visits), the current-year annual hospitalization rate decreased as the prior-year annual outpatient visits increased and statistically significant, and the regression coefficient was not significant when the prior-year annual outpatient visits were higher than the threshold (12 visits). Correspondingly, the thresholds for annual outpatient expenses and annual outpatient self-expenses within policy in the previous year were 3 342.8 yuan and 736.9 yuan, respectively. Conclusion: There is a threshold effect of prior-year annual outpatient service utilization on the current year' s annual hospitalization rate in heart failure patients. These results have important implications for designing outpatient health insurance policies for heart failure patients to improve the patients' utilization of outpatient services and decrease the hospitalization rates. Specifically, policymakers should consider the identified thresholds when designing reimbursement policies for heart failure patients, which may help to optimize the use of medical resources and reduce the burden of medical expenses.

Key words: Urban Employee Basic Medical Insurance, Heart failure, Outpatient services utilization, Hospitalization rate, Threshold effect

中图分类号: 

  • R197.1

表1

心力衰竭患者2017年基本情况(n=7 243)"

Items Data
Gender (Female), n(%) 3 087 (42.6)
Age, n(%)
    ＜50 years 828 (11.4)
    50-59 years 1 289 (17.8)
    60-69 years 1 559 (21.5)
    70-79 years 1 600 (22.1)
    ≥80 years 1 967 (27.2)
Annual hospitalization, n(%) 2 237 (30.9)
Rehospitalization within 30 days, n(%) 618 (27.6)
Rehospitalization within 90 days, n(%) 947 (42.3)
Annual outpatient visits, median (IQR) 24 (27)
Annual outpatient expenses/yuan, median (IQR) 6 240.7 (8 761.5)
Annual outpatient drug expenses/yuan, median (IQR) 2 389.0 (7 131.7)
Annual outpatient self-expenses within policy/yuan, median (IQR) 1 334.2 (2 239.0)
Having annual outpatient drug expenses, n(%) 4 994 (68.9)

表2

浙江省上年门诊服务利用对当年是否住院的影响(Logistic回归)"

Items Annual hospitalization rate Rehospitalization rate within 30 days Rehospitalization rate within 90 days
Model 1 Model 2 Model 1 Model 2 Model 1 Model 2
Annual outpatient visits
    Coefficient -0.14*** -0.16*** -0.025 -0.10 -0.047 -0.14
    95%CI -0.22, -0.07 -0.25, -0.07 -0.18, 0.13 -0.31, 0.10 -0.19, 0.10 -0.32, 0.05
    n 13 563 8 280 2 770 1 449 3 361 1 866
Annual outpatient expenses
    Coefficient -0.13*** -0.15*** -0.009 0 -0.034 0.002 8 -0.024
    95%CI -0.18, -0.08 -0.21, -0.09 -0.10, 0.09 -0.17, 0.10 -0.09, 0.10 -0.15, 0.10
    n 13 856 8 501 2 833 1 496 3 430 1 916
Annual outpatient drug expenses
    Coefficient -0.12*** -0.14*** -0.020 -0.013 -0.040 -0.063
    95%CI -0.18, -0.07 -0.21, -0.07 -0.13, 0.09 -0.16, 0.13 -0.15, 0.07 -0.20, 0.07
    n 10 281 6 272 2 328 1 198 2 757 1 527
Annual outpatient self-expenses within policy
    Coefficient -0.096*** -0.14*** -0.088 -0.086 -0.057 -0.11
    95%CI -0.15, -0.04 -0.20, -0.07 -0.20, 0.02 -0.23, 0.06 -0.16, 0.04 -0.25, 0.03
    n 11 971 7 263 2 526 1 331 3 031 1 693
Whether have annual outpatient drug expenses
    Coefficient -1.24*** -1.17*** -0.11 -0.22 -0.61** -0.75***
    95%CI -1.43, -1.04 -1.38, -0.96 -0.50, 0.28 -0.68, 0.23 -1.00, -0.23 -1.20, -0.31
    n 20 909 14 769 3 888 2 378 4 880 3 166

表3

年门诊服务利用对年住院率的阈值效应(阈值回归)"

Variables of annual outpatient services Model 1 Model 2
Threshold Coefficients P value Threshold Coefficients P value
Annual outpatient visits ≤12.0 -0.165 0.069 ≤14.3 -0.286 0.002
>12.0 -0.138 0.787 >14.3 -0.116 0.111
Annual outpatient expenses/yuan ≤3 342.8 -0.083 0.059 ≤2 677.4 -0.108 0.064
>3 342.8 -0.149 0.207 >2 677.4 -0.171 0.351
Annual outpatient drug expenses/yuan ≤1 374.8 0.048 0.524 ≤1 169.7 0.018 0.847
>1 374.8 -0.155 0.012 >1 169.7 -0.169 0.059
Annual outpatient self-expenses within policy/yuan ≤736.9 -0.086 0.089 ≤983.7 -0.209 ＜0.001
>736.9 -0.100 0.807 >983.7 -0.086 0.071
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ISSN 1671-167X
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