医改十大难点及其破解对策

目前，我国医疗体制改革已进行到第三年了，在医改过程中，国家投入资金8500亿元，完善了社会保障体系，城市城镇职工医保、居民医保、农村新农合制度的建立、对基层医疗机构的改革，基本药物制度的实施，药品“0”加价，九项公其卫生服务等，都给群众带来了实惠，极大地缓解了群众看病难、看病贵的问题。但是，目前在改革过程中仍存在一些问题和一些不健康的现象。     

我国分级诊疗制度实施情况分析

文章概述了我国分级诊疗的发展历史和目前分级诊疗的几种模式;总结了新医改后我国分级诊疗制度实施对促进双向转诊、降低医疗费用和提高基层医疗机构服务的效果。分析了目前分级诊疗制度实施中仍存在基层医疗机构服务能力不足、病人流向并未发生根本性转变、居民对分级诊疗认知程度低,医保配套措施不完善等问题,提出应通过提高基层医疗机构服务能力,加强不同级别医疗机构间的分工协调、疏通双向转诊,加强宣传,提高居民对分级诊疗和基层首诊知晓率,完善医保配套政策措施等建议,以推动分级诊疗的实施。     

新会区医共体人民医院总院医学影像诊断中心建设研究与实践

新会区医共体人民医院总院医学影像诊断中心以互联网+医疗的建设模式,突破时空限制,通过设备升级、网络互通、统一方案、开展培训、推动互联网医疗、推进结果互认以及完善绩效等手段,全面解决基层卫生院影像检查资源不足、人民群众看病难的问题,降低了重复建设和重复检查成本,实现了检查结果互认共享,提升了基层技术人员素质,为基层医疗机构提供了优质的同质化服务,满足了人民群众的就诊需求。     

新农合门诊统筹报账基金风险分析与防范措施

四川省南江县自2005年开始实施新农合试点工作以来，覆盖面不断扩大，筹资水平不断提高，但受益面还是偏窄，3年来新农合基金结余较多，2008年开展了新农合门诊统筹报账，但也面临着基金总量不足、医疗费用上涨过快和医疗服务环节、监管环节等多方面的基金风险。文章结合南江县在开展门诊统筹报账试点工作中的有益探索，认为要搞好门诊统筹报账，必须要科学制定补偿方案，严格控制医疗费用上涨，严格定点医疗机构准入．提高基层医疗机构服务能力，在强化医疗机构监管上狠下功夫，才能确保新农合基金的安全。     

大型公立医院对口支援县级医院的实践与思考

为将基本医疗卫生服务作为公共产品来满足全民需求,我国不断加大对基层医疗机构的扶持力度,以提高基层医疗机构医疗水平和服务能力,缓解偏远地区群众“看病贵、看病难”问题。通过对哈尔滨医科大学附属第一医院对口支援县级医院工作的回顾．总结了对口支援县级医院所取得的成果,提出了进一步完善对口支援工作的对策。     

大医院看病难住院难和社区卫生服务机构资源闲置成因分析与对策

针对我市大医院门急诊量迅速上升、看病住院预约时间过长、社区卫生服务机构工作量不足等现象,我们进行了<大医院看病难、住院难和社区卫生服务中心部分资源闲置成因分析>课题研究.通过调查分析表明,30年来大医院的发展规模总体上与社会经济发展速度相适应;看病难、住院难是由于外来人口增长过快、就医需求快速增长、就医结构发生倒置、医院工作效率不高、受传统就医理念影响、医保政策引导不力、社区卫生服务机构能力不强等因素造成.提出了要调整医保政策,推行社区首诊制和完善双向转诊制度,进一步加强基层医疗机构能力建设;大医院要进一步优化医疗服务流程,努力提高医院工作效率;要研究制订相应优惠政策,积极鼓励和进一步加快民营医疗机构的建设与发展速度等缓解大医院看病难、住院难和使社区卫生服务机构资源得到有效利用的相关对策.     

声誉机制——一种有效的激励机制

据调查,在2010年实施的基层医疗机构绩效工资制度中,各地卫生行政部门普遍给卫生院和社区卫生服务中心医务人员设置了两个绩效考核指标：一是门诊量,二是均次门诊费用。前一个指标反映基层医疗机构解决城乡居民“看病难”问题的程度,后一个则反映解决城乡居民“看病贵”问题的程度。但事实上,医务人员很容易操纵这两个指标。调研中发现,财政全额发放工资以后,各地出现了诱导轻病病人甚至无病者多看门诊的情况,     

探索县强镇活村稳改革可行路径

<正>近年来,广州市花都区围绕"建机制、稳队伍、增活力",探索出基层综合改革的新路径和优质、高效、低耗整合型医疗服务体系,有效缓解了农民看病难、看病贵问题,提升了人民群众对改革的获得感,群众满意度维持在90%以上。花都区围绕为群众提供一体化服务目标,实施村医入编、县镇一体化管理、柔性引才等政策,进一步完善三级医疗服务网络。组建两家医疗集团,医疗集团对政府办基层医疗机构实行机构、资产、业务、人事     

社区医院政策创新对基层医疗机构影响研究

目的：了解社区医院相关政策创新对基层医疗机构卫生服务能力的影响,为横向扩大全市社区医院试点面提供依据。方法：调查江苏省首批18家社区医院创建情况,对社区医院的财政政策相关指标、医改政策相关指标、人力资源相关政策指标和绩效政策相关指标进行统计描述和分析。结果：财政政策相关指标结果表明,通过开展社区医院政策创新,政府加大了对基层医疗机构的财政投入。医改政策相关指标表明,通过开展社区医院政策创新,加强了基层医疗机构的基础设施建设和医疗设备配备;基层医疗机构医疗服务供给量逐步增长,医疗服务质量稳步提升,门诊常见病、多发病诊治能力不断提高;临床、医技等科室设置逐步健全,基层特色科室品牌得到认可。人力资源相关政策指标表明,通过开展社区医院政策创新,基层卫生人才队伍总量增加、结构优化,全科医生人才规模不断扩大。绩效政策相关指标表明,通过开展社区医院政策创新,基层骨干人才薪酬待遇得到了提高,充分调动了基层医务人员的积极性。结论：通过开展社区医院建设试点,完善了基层医疗卫生服务体系,提升了基层医疗卫生服务能力和健康服务水平,促进了更多的人才技术、财力物力、保障政策向基层倾斜。应继续加大社区医院相关政策创新推进力度,积极营造有利于社区医院建设的发展环境,横向扩大全市社区医院的试点面。     

整合型支付:内涵、作用和实现条件*

医疗服务纵向整合是分级诊疗的重要内容，然而现有的医保支付方式的支付对象多为单个医疗机构，对机构间协作的激励不足。文章以“支付方式促进医疗服务体系纵向整合”为出发点，提出了“整合型支付”的概念，即以促进医疗机构间纵向服务连续和功能整合为目标的医保支付方式，并对其作用路径进行了分析，从管理考核、利益分配、薪酬绩效、 服务设计、信息建设等几个方面提出了整合型支付的实现条件。     

Calcium intake in the elderly: validation of a dietary questionnaire

Epidemiological studies of calcium and osteoporosis have been hampered by the lack of a suitable tool for assessing calcium intake. This report describes a new frequency and amount questionnaire for measuring present and past calcium intake in the elderly. The validity of the questionnaire was tested against two commonly used standards of dietary assessment, five-day duplicate diets and seven-day weighed dietary inventories. The resulting correlation coefficients were, respectively, r = 0.76 and r = 0.69, while that for repeatability was r = 0.84. Furthermore, the questionnaire categorized subjects into thirds of the distribution of intake with almost no gross misclassification. It is suggested that the present findings may be extended to the majority of normal, healthy elderly subjects, implying wide application for the questionnaire in the assessment of calcium intake in the elderly.     

The occurrence of antimicrobial substances in toilet,sink and shower drainpipes of clinical units: A neglected source of antibiotic residues

Antibiotics represent one of the most important drug groups used in the management of bacterial infections in humans and animals. Due to the increasing problem of antibiotic resistance, assurance of the antibacterial effectiveness of these substances has moved into the focus of public health. The reduction in antibiotic residues in wastewater and the environment may play a decisive role in the development of increasing rates of antibiotic resistance. The present study examines the wastewater of 31 patient rooms of various German clinics for possible residues of antibiotics, as well as the wastewater of five private households as a reference.To the best of our knowledge, this study shows for the first time that in hospitals with high antibiotic consumption rates, residues of these drugs can be regularly detected in toilets, sink siphons and shower drains at concentrations ranging from 0.02?μg·L^?1 to a maximum of 79?mg·L^?1. After complete flushing of the wastewater siphons, antibiotics are no longer detectable, but after temporal stagnation, the concentration of the active substances in the water phases of respective siphons increases again, suggesting that antibiotics persist through the washing process in biofilms. This study demonstrates that clinical wastewater systems offer further possibilities for the optimization of antibiotic resistance surveillance.     

The human drama of genetics: 'hard' and 'soft' media representations of inherited breast cancer

This paper examines media coverage of 'breast cancer genetics', and explores its implications for public understanding. We present a content analysis of coverage in British newspapers and look at a variety of popular forms, including women's magazines, television soap opera and radio drama. Genetic/inherited risk receives a great deal of coverage across a wide range of media formats and outlets. Much of this attention has focused on individuals from 'high risk families' and dilemmas around prophylactic mastectomies. Through examining media coverage, combined with interviews with media personnel and their sources, we show why this story proved so attractive to the media and highlight the different production values which influence coverage. Finally, we introduce preliminary findings from focus group discussions to demonstrate how such 'human interest' framing has engaged audience attention and influenced public understandings. The paper concludes by highlighting the implications for analysing, predicting, and engaging with, media representations of science.     

Fatigue and health in a seafaring population

Background Occupational fatigue is relatively common withinthe general population and has been linked to reduced performance,injury and longer term ill-health. Despite growing acknowledgementof this problem in the maritime sector, little research hasbeen conducted into the risk factors, prevalence and consequencesof seafarers' fatigue. Aims To examine the prevalence of fatigue among seafarers, identifypotential risk factors and assess possible links with poor performanceand ill-health. Methods Cross-sectional questionnaire survey of seafarers workingin the offshore oil support, short-sea and deep-sea shippingindustries. A number of tools were used including the fatiguesubscale of the profile of fatigue-related symptoms, the CognitiveFailures Questionnaire, the General Health Questionnaire andthe SF36 General Health scale. Results In all, 1855 questionnaires were completed giving anoverall response rate of 20%. Fatigue symptoms were associatedwith a range of occupational and environmental factors, manyunique to seafaring. Reporting a greater number of risk factorswas associated with greater fatigue [e.g. OR = 2.53 (1.90–3.35)for those with three or four risk factors and OR = 9.54 (6.95–13.09)for those with five or more risk factors]. There was also astrong link between fatigue and poorer cognitive and healthoutcomes, with fatigue the most important of a number of riskfactors, accounting for 10–14% of the variance. Conclusions Seafarers' fatigue could impact on safety withinthe industry and may be linked to longer term individual ill-health.It can only be addressed by considering how multiple factorscombine to contribute to fatigue.     

深圳公立医院管理体制改革制度设计

深圳公立医院管理体制改革实行政事分开、管办分开,在理事会架构下按法定机构模式组建市医管中心,落实公立医院运营管理自主权.作者从当前公立医院管理体制的弊端入手,介绍了深圳市进行公立医院管理体制改革的基本思路及改革方案设计的主要举措,深入剖析了的改革方案的特点,并对改革效果进行了预测.     

Self-reported health problems among Swedish miners one year after unemployment

Unemployment is considered to be a public health concern sincedeterioration in the health of the unemployed is often anticipated.However, for some groups, such as miners, unemployment mightimprove health due to a cessation of potentially harmful occupationalexposures. This study evaluates the health of 79 miners in oneSwedish iron-ore mine, and 226 age-matched controls from thegeneral population, during one year after the closure of themine. The participants received a questionnaire regarding medicalhistory and subjective symptoms at the beginning of the studyperiod, and after one year. Statistically significant negativeeffects on self-reported health attributable to unemploymentwere not found, although neuropsychiatric symptoms were morecommon among the unemployed miners. The miners reported a statisticallysignificant improvement in grip force (p=0.031). They had asignificantly higher prevalence of symptoms associated withmining related exposures when compared with the population controls;pain in the upper extremities [relative risk (RR)=2.27, 95%confidence interval (Cl)=1.44–3.59), back pain (RR=1.84;Cl=1.237–2.75), vasospastic disease of the fingers (RR=2.05;Cl=1.18–3.57) and obstructive respiratory symptoms (attacksof dyspnea and wheezing: RR=3.67; Cl=1.167–11.6).     

Excès de cas humains et animaux de tularémie en France au cours de l’hiver 2007–2008 : émergence ou phénomène isolé ?

Context

Tularemia is a zoonosis affecting humans and hares in France. We describe the results of surveillance in both species, in 2007 and 2008.

Methods

Human tularemia cases are mandatorily notifiable in France since 2003. In hares, surveillance relies on volunteer hunter associations in all districts of the country. Data from mandatory reports and volunteer surveillance in 2007/2008 were analyzed and compared with previous results.

Results

In 2007/2008, 144 cases were reported in humans and 117 cases in hares. This was a 100% increase compared to previous years. Human cases differed from those of previous years only by the frequency of contact with breeding animals. Human cases without any documented risk exposure were also more frequent.

Conclusion

An increase of tularemia cases occurred in 2007/2008 in both species. Complementary studies are needed to identify the species reservoir in France to understand the causes of this peak of cases.     

Effects of nitrogen dioxide on red blood cells of rats: Changes in components of red cell membranes during in vivo exposure to NO2

Red cell membranes, prepared from red blood cells of rats exposed to 4, 10, or 20 ppm nitrogen dioxide (NO₂) for 1 to 10 days, were examined for evidence of changes in membrane components. Appreciable changes were not found in contents of phospholipid and cholesterol during exposure to 10 ppm NO₂. By contrast, protein content altered with the time of exposure. Moreover, changes in protein composition were observed by employing sodium dodecyl sulfate — polyacrylamide gel electrophoresis. Twenty-four-hour exposure to NO₂ at the concentration above 10 ppm resulted in a marked increase in the percentage of lysophosphatidylethanolamine (LysoPE) to the total phospholipids. The prolonged exposure to 10 ppm NO₂ gave rise to a further increase in LysoPE, whereas the percentage of phosphatidylethanolamine (PE) showed a gradual decrease. A 1-day exposure to 4.0 ppm NO₂ also caused an increase in sialic acid content and decreases in those of PE and hexose. In addition to contents of these components the percentage of LysoPE increased 5 days after exposure and the elevated values were maintained up to the end of exposure period. These results demonstrate that red blood cells in circulation exhibit different membrane properties in terms of lipid and carbohydrate composition during 10 days of exposure to 4.0 ppm NO₂.     

Occupational health hazards in mining: an overview

This review article outlines the physical, chemical, biological, ergonomic and psychosocial occupational health hazards of mining and associated metallurgical processes. Mining remains an important industrial sector in many parts of the world and although substantial progress has been made in the control of occupational health hazards, there remains room for further risk reduction. This applies particularly to traumatic injury hazards, ergonomic hazards and noise. Vigilance is also required to ensure exposures to coal dust and crystalline silica remain effectively controlled.