新型农村合作医疗中医疗服务供方道德风险的防控

委托一代理理论的基本假设是信息不对称，认为代理人较之委托人在交易中有信息优势，导致代理人为追求自身利益最大化而产生道德风险问题。新型农村合作医疗（以下简称新农合）中存在医疗服务供方（定点医疗机构及医生）、被保险方（医疗服务需方）和保方（经办机构）三方当事人。医疗服务供方同时是被保险方和保方的代理人，三方之间由于信息不对称、疾病治疗的不确定性以及目标不一致，使得被保险人即使有动机去监督医疗服务成本也没有足够的能力去监督，而由于利益的驱使，供方会想尽办法增加其收入，这就形成了“供方诱导下过度消费”的道德风险问题，而且这种供方道德风险的现象极为普遍和突出。因此，对供方的监督约束和激励理应成为新农合监管者关注的重点。     

城镇居民医疗保险中道德风险的防范与控制

诱导需求、过度消费和医患合谋等诱发的道德风险,严重影响了城镇居民医疗保险事业的健康发展.信息不对称是道德风险产生的根源,疾病治疗的不确定性为道德风险提供了滋生的土壤,传统付费方式的缺陷和以药养医的医疗服务价格补偿机制是引发道德风险的外部条件和内部动因.要加强对医疗服务供方和需方的有效约束与控制,增加博弈成本,防范和控制道德风险,推动城镇居民医疗保险事业持续、稳定、快速发展.     

医疗服务中道德风险的博弈分析

在中国目前的医疗体制下,医疗服务市场中医患双方是博弈的主体。由于医疗服务的特殊性,造成医院和患者这两个主体之间的信息不对称,患者在医患双方博弈中明显处于弱势地位。在引入第三方(各种保险)后,可看成患者与医院(医生)和各种保险机构之间的双重博弈,而在这种博弈中,患者总是处于信息弱势地位,利益可能受到双重侵害。实际上,引入第三方购买有效控制的只是增加了医患信息不对称导致的医疗服务提供方的道德风险,而对医患信息不对称导致医疗服务需求方的道德风险作用不大,并有可能扩大这种道德风险。     

医疗服务中道德风险的博弈分析

在中国目前的医疗体制下,医疗服务市场中医患双方是博弈的主体.由于医疗服务的特殊性,造成医院和患者这两个主体之间的信息不对称,患者在医患双方博弈中明显处于弱势地位.在引入第三方(各种保险)后,可看成患者与医院(医生)和各种保险机构之间的双重博弈,而在这种博弈中,患者总是处于信息弱势地位,利益可能受到双重侵害.实际上,引入第三方购买有效控制的只是增加了医患信息不对称导致的医疗服务提供方的道德风险,而对医患信息不对称导致医疗服务需求方的道德风险作用不大,并有可能扩大这种道德风险.     

信息不对称对医患关系的不良影响及其改善策略

医患间信息不对称源于医疗服务的不确定性、信息搜寻的高成本性和患者专业知识的匮乏等原因。医患间信息不对称容易引发医院从自身利益出发损害患者利益的道德风险,也导致患者在医疗市场中的逆向选择,从而无法通过消费者的选择对医院形成有效约束。缓解信息不对称,需要建立信息披露制度、构建医疗服务市场信誉机制,医院也要将信息沟通纳入日常管理。     

引进健康管理促进医患关系和谐

在市场经济条件下，医院和患者构成了医疗服务的供方和需方，而医患关系最重要的特征之一就是信息不对称。由于医疗行业的高度专业性和技术性，医生对医疗知识和技术有足够的了解，患者不仅由于个体搜集、吸收和处理医疗信息的能力有限，而且由于信息传递的不完全和不充分，往往处于医疗信息的劣势地位。患者在就医之前一般会对医疗服务的质量和价格等信息进行了解，     

信息不对称下的医疗服务系统管理

由于医疗服务的特殊性，医疗服务市场上供求双方的信息不对称问题比一般商品更为严重，并造成了医疗服务供方的败德行为、难以避免的医患纠纷以及供求双方的不公平交易。因此，应加强对医疗服务系统的管理，包括完善信息披露制度、引入市场竞争机制、加强医患沟通、改革利益分配机制、加强医疗服务价格监管等。     

如何防范医疗保险中的道德风险

存在信息不对称的医疗保险市场很容易产生道德风险。在我国,医疗保险中的道德风险问题一直表现得非常突出,医生和患者为了各自利益的最大化而过度提供或过度索取医疗服务,造成了医疗费用不合理的大幅度增长,也带来了医疗资源的大量浪费。文章通过探讨在医疗保险中道德风险的表现、成因及其影响,对道德风险的防范提出了相应的对策。     

医疗保险运行中的医疗服务管理

由于卫生服务过程中存在着信息不对称、代理消费、需求价格弹性小等特征，使卫生服务市场成为供方主导的市场，医疗服务供给方的偏好、倾向和决策决定了需方在卫生服务过程中的选择。因此，在医疗保险运行中加强医疗服务管理、确保医疗供方行为的合理、规范，对于控制卫生费用的不合理上涨，推动医疗保险的良性发展具有决定性意义。笔者认为，在医疗保险运行中，     

移动互联网医疗医患矛盾风险分析

移动互联网医疗对医患信息不对称的影响具有两面性,信息不对称仍然客观存在,医患矛盾风险依然突出。移动互联网医疗医患矛盾主要特征包括患者的逆向选择、医生的道德风险和技术安全风险。由此,防范路径主要包括构建以"患者"为中心的医疗服务,消除信息不对称的隔膜;加大医生行政松绑力度,打破原有利益格局;完善移动互联网医疗服务的法律法规,防控系统风险。     

Involving lay and professional stakeholders in the development of a research intervention for the DEPICTED Study

Aim This paper focuses on stakeholders’ active involvement at key stages of the research as members of a Stakeholder Action Group (SAG), particularly in the context of lay stakeholder involvement. Some challenges that can arise and wider issues (e.g. empowerment, the impact of user involvement) are identified and explored within the literature on service user involvement in health care research, reflecting on the implications for researchers. Background In the DEPICTED study, lay and professional stakeholders were actively involved in developing a complex research intervention. Lay stakeholders comprised teenage and adult patients with diabetes, parents and patient organization representatives. Professional stakeholders were from a range of disciplines. Methods Three 1‐day research meetings were attended by 13–17 lay stakeholders and 10–11 professional stakeholders (plus researchers). The SAG was responsible for reviewing evidence, advising on developing ideas for the research intervention and guiding plans for evaluation of the intervention in a subsequent trial. Formal evaluations were completed by stakeholders following each SAG meeting. Results Throughout the first (developmental) stage of this two‐stage study, lay and professional stakeholders participated or were actively involved in activities that provided data to inform the research intervention. Lay stakeholders identified the need for and contributed to the design of a patient‐held tool, strongly influenced the detailed design and content of the research intervention and outcome questionnaire, thus making a major contribution to the trial design. Conclusion Stakeholders, including teenagers, can be actively involved in designing a research intervention and impact significantly on study outcomes.     

中国六城市医务人员戒烟服务的效果评价

目的评价6个城市医务人员提供戒烟服务的实施效果,探讨我国医务人员戒烟服务的工作模式。方法在北京、上海、天津、长沙、深圳和濮阳6个城市7个社区的所有医疗机构负责人和医务人员做戒烟服务研究,进行现场问卷调查。结果干预后共有25家医疗机构开展戒烟服务。医务人员对烟草危害相关知识的知晓率增加了12.8%(P<0.05),掌握戒烟方法和技巧的比例增加了9.2%(P<0.05),主动向病人提供戒烟服务的比例增加了7.3%(P<0.05)。结论培训不但是提高医护人员烟草相关知识和促进医护人员主动提供戒烟服务的有效措施,而且是其获得戒烟方法和技能的有效途径。     

慢性阻塞性肺疾病的康复护理干预

目的探讨慢性阻塞性肺疾病的康复护理干预措施。方法将140慢性阻塞性肺疾病平稳期的患者随机分为观察组和对照组各70例,分别采用康复护理干预措施和常规护理方法。结果观察组采用康复护理干预措施后,患者的生存质量得到明显的提高,与对照组比较差异有显著性（P〈0．05）。结论康复护理干预措施可以提高慢性阻塞性肺疾病患暑生活质量,值得积极推广应用。     

The effect of computer-mediated social support in online communities on patient empowerment and doctor-patient communication

In the context of diabetes, this study tested a mechanism through which Korean diabetes patients' exchange of computer-mediated social support (CMSS) in diabetes online communities influences their sense of empowerment and intention to actively communicate with the doctor. Analysis of data from 464 Korean diabetes patients indicates significant relationships among diabetes patients' online community activities, perceived CMSS, sense of empowerment, and their intention to actively communicate with the doctor. Diabetes patients who have engaged more in online community activities perceived greater social support from other members of the community. Perceived CMSS significantly predicted their intention to actively communicate with the doctor through sense of empowerment. Sense of empowerment was a valid underlying mechanism that explains how patients' perceived CMSS influences their intention to actively communicate with the doctor. The implications for health communication research and practice are discussed.     

心理干预对乳腺癌化疗患者心理状态效果观察

目的:探讨心理干预对乳腺癌首次化疗患者心理状态的效果.方法:采用焦虑自评量表(SAS)及抑郁自评量表(SDS),对30例术后首次化疗的乳腺癌女性患者进行心理干预.在干预前后进行心理状况测评,然后比较护理干预前后效果.结果:30例乳腺癌首次化疗的女性患者均有不同水平的焦虑、抑郁情绪,心理干预后焦虑、抑郁评分均下降,两者相比较差异有统计学意义(P<0.01).结论:心理干预能改善乳腺癌首次化疗患者焦虑、抑郁心理,促进患者积极参与治疗,提高疾病的愈后.     

对建筑工人及工程监理艾滋病干预效果的量化分析

目的探讨小组参与式艾滋病干预活动数量和时间对建筑工人及工程监理艾滋病知识、态度及行为的干预效果。方法采用随机抽样方法抽取湖北省宜昌至巴东在建高速公路31个建筑营地中的4个营地作为干预点,每季度使用“健康干预工具包”对干预点的建筑工人和工程监理进行一次艾滋病知识及行为干预,历经～年干预后调查目标人群参与干预活动情况和其艾滋病知识、态度及行为的改变情况等。结果（1）共调查目标人群450人;接受干预0、1、2、3、4次后的艾滋病总知晓率分别为78．07％、94.40％、95．50％、96．40％和99．40％;（2）未接受干预与接受1次及以上次数干预目标人群的艾滋病防治一般概念和传播途径的认识提高明显,对艾滋病患者的态度也有显著性改善（P〈0．05）;（3）450人中在过去12个月有19．56％人发生过商业性性行为或临时性行为,接受不同频次干预的目标人群有时可以减少高危性行为的发生,但不是每种行为每次干预都有成效;（4）接受干预的目标人群主动寻求有关HIV／AIDS信息的比率显著上升（P〈0．05）,干预4次后能主动与他人讨论艾滋病（P〈0．05）;（5）干预1～4次后目标人群仍难以真正掌握性病的知识和难以形成正确的就医行为。结论应用“健康工具包”干预至少1次,建筑工人及工程监理不仅能显著提高的艾滋病知识知晓率,降低对艾滋病患者的歧视态度,还能主动寻求有关HIV／AIDS信息,干预多次后能主动与他人讨论艾滋病,值得推广。长达一年的干预对改变建筑工人及工程监理的行为方式,降低不安全性行为的发生率有一定效果,但难以持久,且目标人群难以掌握性病知识和形成正确的就医行为。     

16例原发性肝癌患者介入治疗的护理体会

目的 总结原发性肝癌患者介入治疗的护理经验。方法 回顾性分析65例原发性肝癌患者行肝动脉栓塞化疗189次前后的护理资料。结果 由于护理措施得当,处理及时,本组未发生不能恢复的并发症,患者满意,效果好。结论 做好原发性肝癌患者介入治疗的护理,是保证手术治疗成功的重要因素。     

0~6月龄婴儿早期教育综合干预模式对看护人态度的影响

【目的】 以社区家庭为纽带,了解立足社区的婴儿早期教育的综合干预模式对看护人教养态度的影响。 【方法】 选择2009年11月-2010年3月出生的新生儿422人,干预组202 人,对照组220人。两组婴儿均给予基本的儿童保健服务,干预组在此基础上给予自行设计的早期教育综合干预方案,干预为期6个月,比较综合干预前后两组看护人的育儿知识、态度、行为的变化情况。 【结果】 干预组看护者明显增加了婴儿听音乐及动作训练的频率,并主动参与其他早教课程。 【结论】 对看护人进行早期教育综合干预,可明显改善看护人的育儿知识、态度和行为。     

Participation in occupational health longitudinal studies: predictors of missed visits and dropouts

PURPOSE: The purpose of this study is to determine whether demographics, health, and job factors influence continued participation of employed persons in a longitudinal intervention study of tertiary prevention for work-related low-back disorders (WR-LBDs). METHODS: Four hundred fifty-four actively employed persons had enrolled in an intervention study of back supports and education to promote recovery from a WR-LBD. Baseline values were examined according to whether individuals continued in the study, missed a visit, or dropped out; frequency of missed visits; and early or late dropouts at follow-up intervals of 1, 2, 6, and 12 months. RESULTS: Workers who did not complete all study visits were significantly more likely to be younger and have poorer self-reported health. Individuals with a greater percentage of body fat dropped out early. Significantly more missed visits were observed among those who had arthritis and longer duration of low-back pain symptoms. Job factors did not influence study participation. CONCLUSIONS: Continued participation in a longitudinal study of working adults was influenced by age, health status, and factors related to the primary condition targeted by the intervention study. Strategies aimed at those who report lower levels of health and symptoms related to the condition under study may promote follow-up participation in longitudinal studies. Thus, even among actively employed persons, one should not assume that all workers are "healthy."     

Effects of a population-based smoking cessation programme on smoking in pregnancy.

A controlled study was conducted to evaluate the effects of a low-intensity population-based smoking cessation programme in maternity care clinics. Quitting smoking during pregnancy was assessed by a self-administered questionnaire and verified by hair nicotine concentration. In the intervention area, 58/306 women (19.0%) reported quitting smoking during pregnancy whereas in the reference area the numbers were 22/152 (14.5%) (difference = 4.5%, 95% confidence interval: -2.6%-11.6%). The intervention group indicated that they received more information on adverse effects of smoking, studied the material more actively, and felt that material from maternity care influenced their smoking behaviour more than the reference group.