DRG付费对医生行为和医疗质量的影响研究:以踝关节和脊柱融合术为例

目的探究DRG付费对医生诊疗行为和医疗质量的影响。方法从11家实施DRG付费或模拟测算的三级综合医院中选取12名骨科医生进行半结构化访谈,采用Colaizzi 7步法分析。结果共识别重要陈述308条,形成治疗决策、环节把控、患者管理、医疗质量4项基本结构。DRG付费后,医生更关注住院费用,以检查和手术为代表的诊疗行为发生了变化;医生诊疗行为的改变可能引起医疗质量的变化。结论医生应主动控制成本,制定合理的诊疗方案;医院需强化临床指南的使用,加强对医疗质量的考核,以防范医生不规范诊疗行为的发生。     

病例组合指数的内涵及应用探讨

国内普遍认为病例组合指数(CMI)属于医疗服务能力维度,体现收治疾病的疑难复杂程度和医疗服务的整体技术难度。通过结构方程模型分析发现,CMI与时间消耗指数、费用消耗指数等服务效率维度指标联系更紧密,与DRG组数、入组病例数及总权重等服务能力维度指标联系相对较弱,故应归属医疗服务效率维度。CMI的直接应用主要是对平均住院费用的预测控制及对科室绩效的评价;CMI的间接应用主要是对管理指标的调整/校正。医院管理者应准确把握CMI内涵,恰当应用CMI对不同层级及不同类别住院费用进行预测、评价与控制,并对其他管理指标进行调整后再评价。     

DRG评价方法在肿瘤专科医院应用及问题探讨

目的本研究基于浙江省绩效评价的数据,分析讨论DRG评价方法在肿瘤专科医院的应用及问题,为肿瘤专科医院的评估与发展提供建议。方法利用CMI、RW、DRG组数、时间和费用消耗指数等DRG考核指标,对肿瘤专科医院评价结果进行分析探讨。结果肿瘤专科医院的CMI值排在全省三甲医院最后一位,仅有0.65,DRG覆盖组数最少,平均住院时间最短,平均药费最高,费用消耗指数为1.1略高于全省均值,化学治疗人次占全年出院人次的43.85%。结论 DRG评价方法有一定优越性,但肿瘤专科医院在与其他医院一起评价时具有明显的局限性,使用DRG绩效评价方法评价肿瘤专科医院还需要进一步研究,可适当调整疾病组权重,完善分组器,增加精细化评价指标加以改进。     

DRG在深圳市某区临床重点专科评估中的应用

目的评价并遴选深圳市某区临床重点专科,为该区临床重点专科的发展以及我国临床重点专科的评估提供借鉴。方法将DRG相关指标与传统指标相结合作为该区临床重点专科评估指标体系,运用TOPSIS法计算该区11家医院41个临床专科2016—2018年的总排名。结果该区排名前5位的临床重点专科分别是I医院显微外科、J医院产科、K医院鼻科、K医院耳鼻咽喉科以及D医院骨科,排名后5位的专科分别是H医院风湿病科、D医院泌尿外科、C医院儿科、C医院眼耳鼻喉科以及F医院神经外科。结论该区应加快重点专科发展,形成区域专科优势;促进专科均衡发展,满足基本医疗需求;提高专科服务效率,优化医疗资源配置;依托医疗集团做强专科特色品牌,促进专科差异化发展;进一步提高病历首页质量管理水平。     

Training interventions for healthcare providers offering group-based patient education. A scoping review

ObjectivesTo provide overview of research on training interventions for healthcare providers aimed at promoting competencies in delivering group-based patient education.MethodsA systematic literature search identified relevant studies. Data was extracted on training details, study design, outcomes and experiences. Results were summarized and qualitative data analyzed using content analysis.ResultsTwenty-seven studies exploring various training interventions were included. Ten studies used qualitative methods, eight quantitative and nine mixed methods. Use of a comparison group, validated instruments and follow-up measures was rare. Healthcare providers’ reactions to training were mostly positive. Several studies indicated positive short-term effects on self-efficacy and knowledge. Results on observed skills and patient outcomes were inconclusive. Results on healthcare providers’ experience of delivery of group-based patient education following training were categorized into 1) Benefits of training interventions, 2) Barriers to implementation and 3) Delivery support.ConclusionsFurther evaluation of training for healthcare providers delivering group-based patient education is needed before conclusions on training efficacy can be drawn. The results indicate an expanding research field still in maturation.Practice implicationsEfficacy studies evaluating theoretically grounded training with clear attention on group facilitation and follow-up support are needed. Inclusion of validated instruments and long-term outcomes is encouraged.     

Predicting healthcare expenditure by multimorbidity groups

Objectives

This article has two main purposes. Firstly, to model the integrated healthcare expenditure for the entire population of a health district in Spain, according to multimorbidity, using Clinical Risk Groups (CRG). Secondly, to show how the predictive model is applied to the allocation of health budgets.

One or two doses of hepatitis A vaccine in universal vaccination programs in children in 2020: A systematic review

BackgroundHepatitis A virus (HAV) is a global health concern as outbreaks continue to occur. Since 1999, several countries have introduced universal vaccination (UV) of children against HAV according to approved two-dose schedules. Other countries have implemented one-dose UV programs since 2005; the long-term impact of this schedule is not yet known.MethodsWe conducted a systematic literature search in four electronic databases for data published between January 2000 and July 2019 to assess evidence for one-dose and two-dose UV of children with non-live HAV vaccines and describe their global impact on incidence, mortality, and severity of hepatitis A, vaccine effectiveness, vaccine efficacy, and antibody persistence.ResultsOf 3739 records screened, 33 peer-reviewed articles and one conference abstract were included. Rapid declines in incidence of hepatitis A and related outcomes were observed in all age groups post-introduction of UV programs, which persisted for at least 14 years for two-dose and six years for one-dose programs according to respective study durations. Vaccine effectiveness was ≥95% over 3–5 years for two-dose programs. Vaccine efficacy was >98% over 0.1–7.5 years for one-dose vaccination. Antibody persistence in vaccinated individuals was documented for up to 15 years (≥90%) and ten years (≥74%) for two-dose and one-dose schedules, respectively.ConclusionExperience with two-dose UV of children against HAV is extensive, demonstrating an impact on the incidence of hepatitis A and antibody persistence for at least 15 years in many countries globally. Because evidence is more limited for one-dose UV, we were unable to draw conclusions on immune response persistence beyond ten years or the need for booster doses later in life. Ongoing epidemiological monitoring is essential in countries implementing one-dose UV against HAV. Based on current evidence, two doses of non-live HAV vaccines are needed to ensure long-term protection.     

Learning in Psychotherapy Group Supervision: Transcending Complementarity and the Generative Potential of Group Conflict

At the site of interpersonal conflict resides the potential for learning. This paper presents psychodynamic theories, empirical research and a fictional case study of psychotherapy group supervision. Supervision is discussed in terms of teaching and learning, triangular relations, and group and organizational perspectives. We examine the interconnectedness of patterns of distress that emerge within dynamic relational systems at the levels of the macro‐social, organizational, group and individual. The concepts of equivalence, parallel process and reflection process provide frameworks for this discussion. We explore the constraints and dynamic influence of the organization upon the supervision relationship and the ethical tensions that construct im/possible positions for the supervisor. The case study tells a fictional story of a supervision group situated in an organizational context – a university psychotherapy education programme. A collapse of the group into complementarity, that is into polarized conflicted positions, proffers a vitalizing opportunity for learning. Through the clinical discussion, we reveal how this is contingent on the group's capacity to think together about the meaning of their struggle and to transcend a binary conflict and achieve ‘the third’.