西藏藏族自治区眼科医疗资源现况调查

背景 眼科医疗保健体系的不断完善是防盲治盲工作的有力保障,但目前西藏自治区的眼科医疗资源分配情况仍不能满足当地防盲治盲工作的需要.了解西藏地区眼科医疗资源现状有助于当地合理分配紧缺的医疗资源,推进防盲治盲工作的开展. 目的 对西藏自治区的眼科医疗资源分配进行调查,为尽快建立该地区的眼科医疗保健网络和有效提供资源供给提供依据. 方法 本研究组于2016年4-6月面向西藏藏族自治区各级医疗单位眼科科室负责人和眼科医生发放西藏自治区医疗机构眼科专业情况调查问卷.西藏地区21家医疗机构的21名眼科科室负责人和52名眼科医生就眼科专业情况参与调查,由经过统一培训的专职人员按照统一调查方式收集整理,以确保回答问卷的真实有效性.结果 所有调查问卷发放的全区覆盖率为100％并全部收回,问卷填写符合要求,应答率及问卷有效率均为100％.截止2016年6月,西藏自治区共有21所有眼科诊疗能力的医疗机构,按照国家统计局公布的2014年西藏人口状况计算,平均每15.1万人拥有1个眼科医疗机构,但无独立眼科专科医院.其中有眼科专科医生者19所,占90.5％,有独立眼科科室者13所,占61.9％,有眼科独立手术室11所,占52.4％.全区眼科共有病床数量120张,平均每10万人拥有眼科医生1.6名,其中硕士学历者3名,尚无主任医师;全区共有专业护士14人,其中全职和兼职者各7人.目前西藏藏族自治区具备了基本的诊断仪器和最基本的手术设备,2015年全区平均眼科手术量为326.2人次.结论 西藏藏族自治区的眼科医疗资源不足,尤其是基层乡镇卫生院和县级医院眼科医疗机构,制约当地眼科防盲治盲工作的开展.     

2007年云南省医疗机构眼科现状调查

目的了解截至2007年云南省的眼科医疗现状和服务能力。设计横断面问卷调查。研究对象云南省内165家医疗机构。方法采用卫生部统一设计的眼科机构现状调查表,于2007年10-12月对云南省内医疗机构的眼科现状进行问卷调查。收集整理并分析问卷结果。主要指标医护人员数量、年手术量、门诊量、可独立完成白内障手术的医生数量。结果参与调查的的165家医疗机构共有眼科医生735名,能独立完成白内障手术者392名,眼科护理人员771人。全省16个地州市中,昭通地区每百万人口拥有的眼科医生资源仅为7人,而昆明市为32人。2006年所有医疗机构共完成眼科各类手术58346例,包括白内障23833例。尚未开展白内障手术的医疗机构有27家。各级医疗机构仅29家（17．6％）拥有较好的眼科设备,6家（3．6％）没有任何眼科设备。结论云南省不同等级和不同地区之问的医疗机构眼科水平差异很大,人力资源分布不均,工作效率较低,需要进一步进行资源整合和优化利用,以满足群众对眼科医疗服务的需求。（跟科,2010,19：142—144）     

我国眼科现状调查研究与分析

目的 了解我国眼科医疗机构的数量、类型、地理分布、人力资源结构及医疗服务和设备使用情况等。方法 1997年11月至1998年6月采用卫生部医政司与全国防盲办统一编制的《眼科现状调查表》,以信函方式调查我国1996年所有已注册的眼科医疗机构,1999年3月应用SAS统计软件对其函调结果进行汇总及分析。结果 1996年我国眼科医疗机构共有4151家,眼科编制床位43204张,眼科医师22577人,眼科技术人员1527人,眼科护理人员16448人。结论 眼科医疗机构分布不合理、人力资源分布不均衡是制约我国防盲治盲工作深入开展的主要原因。     

2013年河北省眼科现状调查

目的：了解河北省眼科目前的基本情况，旨在制定高效、针对性强、切合实际需要的继续教育培训计划。方法本次调查采取问卷调查方式，内容包括基本信息、所在医院及科室信息、个人业务情况、开放性问题4个大项25小项，由各地区眼科学会负责将调查表下发给辖区内所有能够开展眼科临床工作的医疗机构并回收问卷，问卷汇总后河北省眼科学分会根据遗漏情况直接进行电话、信件邮寄、电子邮箱等方式进行补漏。结果本次问卷调查覆盖了141个县市中的121个（覆盖率85.8%），305家医疗机构，1485名眼科医师，各医院眼科医师受训比例高（84.3%），眼科医师期待学习、提高的比例较高（94.8%），本科以上学历比例较高（68.9%），但博士、硕士研究生高学历人才比例不高（19.6%），河北省内能够独立开展玻璃体切除等后节手术的人才偏少（4.1%），不具备基本眼科设备的医疗机构比例较高（37.3%）。结论制约河北省眼科事业发展的原因包括人才和设备的缺乏，河北省眼科目前的主要矛盾是广大人民群众日益增长的对眼科治疗的需要与目前我们所能提供的眼科医疗服务水平之间的矛盾。根据调查结果，河北省眼科学分会将增加组织省内眼科医师期待和有兴趣参加的培训次数，最终达到提高全省眼科水平的目的。（中华眼科杂志，2015，51：499-504）     

山东省部分医疗机构开展翼状胬肉手术情况的问卷调查

目的  分析山东省部分医疗机构翼状胬肉手术的开展情况,以便配合山东省卫生强基工程做好翼状胬肉规范手术的推广。设计  横断面调查。研究对象 参加2009年翼状胬肉手术临床应用技术推广培训班的73所医院。 方法 对来自73所医院的人员进行问卷调查。主要指标 能否开展眼科显微手术、是否配有独立科室及病房、翼状胬肉手术每年开展例数、开展手术方式、术后复发率、认为最恰当的推广方式、培训班最大收获等。结果 现场共发出调查问卷75份,收回73份。省级医院10所（13.70%）,市级医院43所（58.90%）,县区级及以下医院20所（27.40%）。73所（100%）医院均能开展显微手术;68所（93.15%）医院备有独立科室及病房。年手术量小于50例的10所,50～100例的34所,大于100例的29所;开展翼状胬肉切除联合自体干细胞移植术的45所;单纯翼状胬肉切除术的14所;翼状胬肉切除联合羊膜移植术的7所;翼状胬肉切除联合抗代谢药物治疗的7所。省级医院开展翼状胬肉切除联合自体干细胞移植术后复发率＜10%的比例为88.89%,市级医院为58.06%,县区级及以下医院为20%。32所（43.84%）医院认为培训班为适宜推广方式;51所（69.86%）医院认为培训班最大收获是学习手术技巧。结论 翼状胬肉切除联合自体干细胞移植术是目前山东省部分医院采用的主流手术方式,且复发率低。利用培训班授课对规范翼状胬肉手术、提高操作水平有益。（眼科, 2013, 22: 354-356）     

河北省眼科医院2012-2016年青光眼睫状体炎综合征患者就诊构成分析

目的 回顾河北省眼科医院青光眼睫状体炎综合征（简称青睫综合征）的患病情况以及门诊就诊特点。设计 回顾性病例系列。研究对象 2012年至2016年于河北省眼科医院就诊的患者管理系统登记的所有青睫综合征患者286例。方法 回顾河北省眼科医院该时间段门诊及住院管理系统中登记的青睫综合征患者的病历资料，对患者发病年龄、男女比例、季节分布、就诊次数等进行统计分析。主要指标 性别、初诊年龄、年患病率、发病季节、就诊频次。结果 近5年就诊的青睫综合征患者286例527人次 。男性166人（58.0%），女性120人（42.0%）。初次就诊的平均年龄（40.1±15.1）岁，其中20~60岁81.9%，20岁以下及60岁以上者分别占5.6%和12.6%。男性（39.5±15.6岁）和女性（41.0±14.3岁）的初次就诊年龄无统计学差异（P=0.415）。5年累积发病率为16.9/10万，年发病率为3.40/10万。夏季的就诊频次高于其他季节（P=0.006）。5年的年就诊人数及人次无明显变化，72.1%的患者年平均就诊次数少于2次。结论 河北省眼科医院青睫综合征以男性居多，主要集中于20~60岁人群，夏季多发。     

1 238例近视手术患者散光状况分析

目的统计青年近视人群散光状况,分析散光组成和分布特征。方法横断面研究。收集2011年5月至2012年10月在山东医专附属眼科医院准分子激光中心接受近视治疗的1 238例患者（2 476眼）,年龄（21.5±4.1）岁。分别统计这些患者全眼散光度、角膜散光度、晶状体散光度以及散光轴向分布,计算各项所占百分比。结果本组2 476眼中散光眼占65.14%,平均全眼散光度为（0.58±0.62）D,角膜散光占优势地位,平均为（1.06±0.59）D,晶状体散光为（0.58±0.40）D。全眼散光中顺规散光占49.39%,逆规散光占8.19%,斜轴散光占7.56%,单纯近视占34.86%。在角膜散光轴向中,85.26%为顺规性,3.19%为逆规性,6.99%为斜轴散光,4.56%的角膜无散光。在晶状体散光轴向中,4.16%为顺规性,73.10%为逆规性,7.19%为斜轴散光,15.55%的晶状体无散光。引起散光的因素中,单纯角膜散光占13.25%,单纯晶状体散光占1.78%,混合因素引起的散光占81.99%,各因素均无散光占2.99%。结论山东医学高等专科学校附属眼科医院欲行近视手术的青年患者中,角膜散光是眼散光的主要来源,全眼散光和角膜散光以顺规散光为主。     

西北地区眼科单中心1009例单眼盲患者致盲病因和手术疗效分析

目的　分析我国西北地区眼科单中心行白内障手术的单眼盲患者致盲病因和手术效果,为提高防治提供参考。方法　回顾性系列病例研究。纳入2016年7月至2020年11月陕西省眼科医院（西安市第四医院）收治的对侧眼行白内障手术的单眼盲（单眼裸眼视力＜0.05）患者1009例。采用χ²检验及logistic回归分析对患者致盲病因和白内障手术效果进行分析。结果　1009例单眼盲患者中,男465例（46.1%）,女544例（53.9%）,年龄（67.7±11.9）岁。前6种致盲病因分别为青光眼［29.7%（300例）］、视网膜脱离［15.3%（154例）］、眼外伤［14.4%（145例）］、角膜病［6.4%（65例）］、高度近视［6.1%（62例）］、白内障［5.7%（58例）］。对侧眼手术前、后视力完整者989例,术后视力提高者占90.2％（892例）,未提高者占9.8％（97例）;386例单纯白内障患者术后视力均提高,余603例术后视力提高者与未提高者间差异具有统计学意义的相关因素为眼部合并其他疾病及其治疗史(均为P<0.05),进行logistic回归分析后,有意义的独立因素包括青光眼和眼部合并其他疾病治疗史（均为P<0.05）,其中眼部合并其他疾病治疗史回归系数为-2.016,影响最大。结论　青光眼是我国西北地区行白内障手术的单眼盲患者中最常见的致盲病因,且女性多见。单眼盲对侧眼单纯白内障患者在无禁忌证时应尽早行白内障手术。眼部合并疾病尤其青光眼的及时诊治对白内障手术有积极作用。     

基于职业倦怠调查表研究眼视光医学教育体系下视光医师与眼科医师的职业倦怠状况及其相关因素

目的：基于职业倦怠调查表（MBI-GS量表）分析眼视光医学教育体系下视光医师与眼科医师的职业倦怠状况及其相关因素。方法：问卷调查研究。应用修订的MBI-GS量表对121 名眼视光医师（53 名视光医师,68名眼科医师）进行问卷调查,同时对这121名医师行相关因素满意度的问卷调查。采用独立样本t检验、卡方检验、Pearson相关分析、多元逐步线性回归进行数据分析。结果：121 名眼视光医师没有明显的职业倦怠,其中,视光医师情绪衰竭分值为2.11 ± 1.08、玩世不恭分值为1.84 ± 1.41、成就感低落分值为1.71 ± 1.23,眼科医师情绪衰竭分值为2.51 ± 1.22、玩世不恭分值为1.85 ± 1.20、成就感低落分值为1.86 ± 1.19,其中两者的情绪衰竭方面差异有统计学意义（t=-2.043,P=0.040）,同时,MBI-GS评分与各种满意度指标基本都存在着不同程度的相关（P < 0.05）,同时视光医师的情绪衰竭主要与收入情况和健康情况有较密切的关系（F=10.373,P < 0.001）,玩世不恭主要与家庭情况和人际情况有较密切的关系（F=11.768,P=0.0001）,成就感低落主要与家庭情况有较密切的关系（F=6.967,P=0.011）;而眼科医师的情绪衰竭（F=20.943,P < 0.001）,玩世不恭（F=11.497,P=0.001）和成就感低落（F=16.303,P < 0.001）则主要与人际情况有较密切的关系。结论：眼视光行业本身压力和风险较低,医师没有明显的职业倦怠,其中眼科医师比视光医师更容易受人际情况因素的影响,而视光医师的职业倦怠更容易受健康情况和家庭情况的影响。     

50岁及以上眼科住院病人的流行病调查

目的调查50岁及以上眼科住院病人的构成比。方法收集从2002年1月-2004年12月的50岁及以上眼科住院患者,年龄、性别、病种的构成比,运用Stata8.0软件进行数据收集整理分析。结果共有1112例被调查,其中男性591例,女性521例;2002年为339人次,2003年为349人次,2004年为424人次;其中50-60岁为33.27%,60-70岁为37.05%,70-80岁为22.48%,80岁以上为7.10%;三年间白内障患者分别占41%-51.8%,青光眼占19.33%-25.36%,视网膜脱离占10.88%-15.33%,眼外伤为6.78%-10.33%。结论50岁及以上的眼科住院患者有逐年增加趋势,白内障仍然是老年眼病的首要疾病,其次为青光眼、视网膜脱离、眼外伤。     

The Capacity of Eye Care Services for Patients with Glaucoma in Botswana

ABSTRACT

Purpose: To evaluate current delivery of glaucoma care in Botswana; in particular, the service infrastructure available and glaucoma-related workload.

Methods: A multi-center cross-sectional study was undertaken comprising government eye care institutions and ophthalmic personnel across Botswana. Data on human resources, equipment types and numbers, diagnostic criteria routinely used, treatments routinely provided, and new and repeat glaucoma consultations were obtained through quantitative and qualitative surveys.

Results: In 27 government eye care institutions there were two general ophthalmologists, neither of whom had a subspecialty interest in glaucoma, 64 ophthalmic nurses, two optometrists, one low vision therapist, one refractionist, and two equipment technicians. Only 8.5% of available ophthalmic human resources were taken up with provision of glaucoma care. About 1/3 of hospitals did not have tonometers, most primary hospitals lacked slit lamp biomicroscopes and most hospitals lacked sensitive diagnostic equipment. A diagnosis of glaucoma was made by either an ophthalmic nurse or an ophthalmologist, but only 10% of institutions could meet recommendations for follow-up assessment. Topical glaucoma medications were prescribed by almost all hospital clinics, usually by ophthalmic nurses. Drug choices were largely determined by local availability. Glaucoma surgery accounted for 0.8% of total eye operations. Glaucoma patients took up 8.5% of total clinic visits. The total number of glaucoma visits was highest in the two hospitals with ophthalmologists. New glaucoma cases took up 10.3% of total glaucoma visits.

Conclusion: This study highlights the challenges faced in caring for glaucoma patients in Botswana; in particular, lack of professional human resources, equipment and availability of effective treatments.     

医疗机构在感染性眼表疾病屈光检查中的感染控制

在临床工作中,眼科工作人员尤其是视光师在第一线面对感染性眼表疾病患者时,必须肩负起两个艰巨问题,即近视防控和感染防控的双重责任和压力。本文明确了眼科视光师在感染控制、屈光检查设备和场所消毒两个方面的实施细则,以进一步规范眼科屈光检查的临床操作流程,加强感染控制专业知识、方法与技能,降低被感染风险,避免交叉感染。汇总目前各大医疗机构的经验,从预防医学和眼科学角度,为眼科屈光检查时的感染控制提供全面且统一的建议意见。     

Ophthalmology training in sub-Saharan Africa: a scoping review

Sub-Saharan Africa is home to 12% of the global population, and 4.3 million are blind and over 15 million are visually impaired. There are only 2.5 ophthalmologists per million people in SSA. Training of ophthalmologists is critical. We designed a systematic literature review protocol, searched MEDLINE Ovid and Embase OVID on 1 August 2019 and limited these searches to the year 2000 onwards. We also searched Google Scholar and websites of ophthalmic institutions for additional information. We include a total of 49 references in this review and used a narrative approach to synthesise the results. There are 56 training institutions for ophthalmologists in eleven Anglophone, eleven Francophone, and two Lusophone SSA countries. The median duration of ophthalmology training programmes was 4 years. Most curricula have been regionally standardised. National, regional and international collaborations are a key feature to ophthalmology training in more than half of ophthalmology training programmes. There is a drive, although perhaps not always evidence-based, for sub-specialisation in the region. Available published scientific data on ophthalmic medical and surgical training in SSA is sparse, especially for Francophone and Lusophone countries. However, through a broad scoping review strategy it has been possible to obtain a valuable and detailed view of ophthalmology training in SSA. Training of ophthalmologists is a complex and multi-faceted task. There are challenges in appropriate selection, capacity, and funding of available training institutions. Numerous learning outcomes demand curriculum, time, faculty, support, and appropriate assessment. There are opportunities provided by modern training approaches. Partnership is key.Subject terms: Education, Health occupations     

Ophthalmology in Taiwan

We herein report the current status of ophthalmology in Taiwan. There are 1667 ophthalmologists in Taiwan (up to the year 2011), with an average of 7.22 eye specialists/100,000 people. The ophthalmology residency program is a 4-year course in Taiwan, and around 40–44 new residents pass out each year. The Ophthalmological Society of Taiwan and many other professional ophthalmological organizations, and 30 teaching hospitals provide continuing education for practicing ophthalmologists and hospital staff. From 2002 to 2010, the average yearly cataract surgery rate in Taiwan was 5350/million people. Taiwan has held many international congresses. The major areas of biomedical research in ophthalmology in Taiwan are ophthalmic epidemiology, glaucoma, vitreoretinal diseases, cornea, and stem cells. From 1990 to 2010, Taiwan ophthalmologists have published 15 monographs, 15 textbooks, and 2184 scientific articles. The future objectives of Taiwanese ophthalmologists are to promote preventive ophthalmology, to expand efforts in basic research, to establish a national eye-diseases registry, and to support the Taiwan Journal of Ophthalmology in becoming a Science Citation Index journal.     

Status of pediatric eye care in India

Purpose:

To document the status of pediatric eye care in India.

Materials and Methods:

A list of institutions providing eye care was compiled from various sources, including government officials, professional bodies of ophthalmologists, and national and international non-governmental organizations (NGO) working in the field of eye care in India. A questionnaire on eye care services was sent to all known eye care institutions in the country. Workshops and regional meetings were organized to maximize response. Validity of data was ensured by observational visits to 10% of the institutions who responded.

Results:

Out of 1204 institutions contacted, 668 (55.5%) responded to the questionnaire. Of these, 192 (28.7%) reported that they provided pediatric eye care services. A higher proportion (48.3%) of NGO hospitals reported separate pediatric ophthalmology units compared to other providers (P< 0.001). Eighty per cent of advanced care eye hospitals had dedicated outpatient, and 40% had dedicated inpatient facilities for children (P< 0.001). The advanced eye care hospitals attended to a larger number of pediatric clients (P < 0.001), and performed more pediatric eye surgeries compared to secondary and tertiary care hospitals (P < 0.001). Eighty- three per cent of advanced care centers and 72.4% of NGO hospitals had an anesthesiologist for pediatric eye service. Refractive error was the commonest reason for seeking service. The commonest surgical procedure was pediatric cataract surgery followed by squint surgery.

Conclusion:

Pediatric eye care services are not adequate in India.     

Geographical distribution of eye health professionals and cataract surgery in Lao People’s Democratic Republic

Purpose: To assess the geographical distribution of eye health professionals and cataract surgery procedures in Lao People’s Democratic Republic (PDR) over the last decade.

Methods: The number of ophthalmologists (defined as physicians who have completed full education and training in ophthalmology), eye doctors (defined as physicians who have completed education and training in only cataract surgery), ophthalmic nurses, and cataract surgery procedures across 16 provinces and Vientiane municipal for the middle/late 1990s, the year 2000, and the most recent year (2005–2006) were obtained from the registration system of eye health professionals and the track record in cataract surgeries in the Ophthalmology Center, Ministry of Health. The number of cataract surgeons (total number of ophthalmologists and eye doctors) per million population, the number of ophthalmic nurses per million population, and the cataract surgical rate were calculated for various geographical units using available population data from the census in 1995, 2000, and 2005. The Gini coefficients, measures of inequality that range from 0 (total equality) to 1 (total inequality), were computed at three time points.

Results: The number of ophthalmologists, ophthalmic nurses, and cataract surgery procedures increased in this country as a whole, although the number of eye doctors did not change after 2000. The Gini coefficients for them also improved (Cataract surgeons: 0.792, 0.415, and 0.361; Ophthalmic nurses: 0.448, 0.354, and 0.259 and; Cataract surgery: 0.366, 0.309, and 0.248 in the 1990s, 2000, and 2005-6, respectively).

Conclusion: Imbalances in the geographical distribution of eye health professionals and cataract surgery decreased over the last decade.     

Ophthalmology manpower: Shortfall or windfall?

Forecasts of ophthalmology manpower depend on assumptions about future supply and requirements. The two factors that influence supply are the number of residents trained and the attrition of ophthalmologists in practice. The factors that influence requirements are the estimated amount of future ophthalmic services the public will demand and the productivity of ophthalmologists. Previous forecasts have produced widely differing results because of an inadequate data base and varying theoretical assumptions. A conservative approach is to use past ophthalmologist to population ratios as a guide, and to tailor the output of ophthalmologists accordingly. A yearly reduction from 1982 to 1990 between 5% and 10% in the number of residency positions will be necessary to bring supply in line with requirements within the next thirty years.     

Analysis of New Zealand's research productivity in ophthalmology and vision science: 1993-2002

AIM: To assess New Zealand's research productivity in the area of ophthalmology and vision science over the decade 1993-2002. METHODS: New Zealand-based researchers involved in ophthalmology or vision science research, including ophthalmologists, optometrists and vision scientists were identified via professional colleges, universities and electronic databases. Peer-reviewed publications by these authors were identified by both searching electronic databases (MEDLINE/Pubmed) and personal communication with individual researchers. RESULTS: Eighty-five New Zealand-based researchers involved in ophthalmology or vision science research published 446 articles in 84 scientific journals during the 10-year period. The cohort consisted of 59 ophthalmologists and 26 other researchers based in a diverse range of ophthalmology, optometry and university departments. Significant collaboration was observed between groups within New Zealand and with international institutions. Comparing ophthalmologists and 'other' researchers, ophthalmologists produced 69% of all ophthalmology and vision science research publications and those classified as 'active ophthalmologist researchers' published an average of 11 (range 5-55) papers each during this decade, compared to eight (range 5-25) for the group 'other active researchers'. This was also reflected in the high productivity rate by ophthalmologists of 277 publications per 1000. Publications were identified in a wide range of journals with the majority in top 20-ranked ophthalmology journals. The trend over the decade highlighted an increase in number of scientific publications, from 43 per annum in 1993, to 68 per annum in 2002. CONCLUSIONS: Despite a relatively small and geographically isolated population, New Zealand ophthalmology and vision science research is highly active and collaborative, with significantly increased research productivity during the period 1993-2002. The present study is the first to document these trends and provides strong evidence to justify continued support for ophthalmology and vision science research in New Zealand.     

Reasons reported by African ophthalmologists for staying in Africa and for considering migrating

In sub-Sahara Africa, the shortage of ophthalmologists is a major obstacle in the struggle of fighting preventable blindness. Migration of well-trained ophthalmologists has an additional negative effect on the low number of caregivers. However, to date, the reasons affecting migration of ophthalmologists have not been completely understood. The present study evaluates reasons reported by ophthalmologists for staying in their current work setting/country and potential reasons why they might consider migrating. In the years 2009–2011, after approval was obtained from the Institutional Review Board, a questionnaire evaluating reasons for and against migration of ophthalmologists was distributed to the participants of 2-week courses in Ethiopia, Cameroon and Kenya providing continuing medical education in the field of ophthalmology. A total of 84 ophthalmologists participated in this survey. The main reasons for staying in their current region/country were good working conditions, commitment to help, possibility of further training, familial ties and general feeling of satisfaction. Professional development elsewhere and better income abroad were named as the main reasons for considering migration. Almost half of the survey participants reported good infrastructure, equipment, and consumables, which is encouraging. Programs aimed at continuing medical education of ophthalmologists to enable professional development may have an appropriate role in the establishment of an ophthalmic infrastructure which can meet patients’ needs.