上海市公立三级综合医院医药分开试点对门急诊用药行为的影响

目的:分析和评估医药分开政策对公立三级综合医院医生门急诊用药行为的影响。方法:从医保角度,对4家试点医院和3家对照医院的医生门急诊用药行为进行对比分析。结果:平均每张处方用药品种数、注射剂使用率、基本药物使用率差异不明显,抗菌药使用率试点医院明显低于对照医院;平均每张处方药品费用试点医院高于对照医院,但是处方率试点医院低于对照医院。结论:医药分开政策尚未对医生的用药行为产生明显影响;从医生及患者的用药习惯、药品供销的利益链及医药分开试行范围分析可知,促进医生合理用药仍需综合多方措施。     

深圳市医药分开改革方案的总体设计和创新

根据国家和广东省关于推进公立医院医药分开改革的总体要求,深圳市立足本市实际,提出了医药分开改革的“1+6”综合措施,即以取消公立医院药品加成政策为突破口,同步推进医疗服务支付制度改革、完善公立医院补偿机制、建立药品流通企业与医院药房竞争机制、改进药品采购方式、查处医药购销领域商业贿赂行为和健全公立医院监管机制6项措施.作者详细说明了上述改革措施,并解读了这些策略的创新性.     

Quality and quantity: the role of social interactions in self-reported individual health

The public health literature on the detrimental effects of social isolation has shown that the quantity of social connections is positively correlated with individual health. Drawing on pooled cross-sectional data, we test this hypothesis on a representative sample of the Italian population. Our findings show that, in addition to the quantity of interactions, it is their quality--as measured by subjective satisfaction derived from relationships with friends--that works as the best predictor of self-reported health. The frequency of meetings with friends is significantly and positively correlated with good health in all regressions. However, when we add our measure of the quality of relationships to the probit equations, the statistical significance of "quantitative" measures is scaled down. Satisfaction with relationships with friends exhibits a positive and highly significant coefficient. Results of the multivariate probit analysis point out the potential role of unobservable variables suggesting the existence of endogeneity problems which require further investigation. We point out the existence of health disparities based on socio-economic status. There is a higher probability that poorer and less educated individuals report poor health conditions. The risk is even higher for unemployed and retired workers. This paper contributes to the literature in two substantive dimensions. This is the first empirical study of the relationship between social interactions and health in Italy. Second, we add to previous empirical studies by taking into account not only the frequency of various kinds of meetings but also indicators of their "quality", as measured by agents' subjective satisfaction with their social participation. The reliability of the analysis also benefits from the uniqueness and comprehensiveness of our dataset, which tries to overcome a structural deficiency in Italian data by merging information on agents' behaviours and perceptions with data on household income.     

医养结合下老年人医疗消费行为影响因素分析——以南京市为例

目的:在"医养结合"背景下,老年人能否合理、有效、充分的利用医疗资源,建立良好的医疗消费行为和消费意向,对于实现健康养老、提高老年人生活幸福感具有重要意义。方法:基于南京地区的微观调查数据,利用计划行为理论和结构方程模型对影响该地老年人医疗消费行为和消费意向进行系统分析,从行为态度、主观规范和知觉行为控制分析医疗消费行为的影响因素。结论:老年人感知看病行为的难易程度与其医疗消费行为意向不存在显著因果关系;老年人的医疗消费行为意向受到其所处的社会网络中各类社会关系的影响;老年人的医疗消费行为受到行为信念、规范信念、行为态度和主观规范的作用。     

Inadequate recording of alcohol-drinking,tobacco-smoking and discharge diagnosis in medical in-patients: failure to recognize risks including drug interactions

Summary. The records of 62 men and 43 women, 14–88 years old, admitted to general medical wards in a public teaching hospital during 1991 were examined for discharge medications and for the recording of alcohol-drinking, tobacco-smoking and discharge diagnosis. Drinking and smoking status was unrecorded in 22.9% and 21.9% of patients respectively. Twenty-four patients had 31 potential drug interactions which were related to the number of drugs prescribed and to drinking alcohol; 10.5% of the patients had interactions involving alcohol and 2.9% tobacco. Six patients received relatively or absolutely contraindicated drugs, including one asthmatic given two β-blockers. The drugs prescribed indicated that some patients had conditions such as gastro-oeso-phageal disorders, diabetes and obstructive airways disease which had not been recorded. Inadequate recording of diagnoses, alcohol and smoking status creates risks to patients and may cause opportunities for preventive care to be missed. This study provides the basis for the development of undergraduate and postgraduate education programmes to address these issues and so decrease risks to patients which arise from inadequate recording practices. Incomplete diagnoses also adversely affect hospital funding where this depends on case-mix diagnostic groups. Quality assurance programmes and other strategies are being implemented to improve medical recording and prescribing habits.     

医学应对方式与社会支持对艾滋病病毒感染者/病人生存质量影响的研究

目的探讨社会支持与应对方式对艾滋病病毒感染者/病人生活质量的影响。方法采用Feifel等编制的医学应对问卷、肖水源等编制的社会支持评定量表以及美国波士顿健康研究所编制的健康状况调查问卷对57例艾滋病病毒感染者/病人进行问卷调查。结果艾滋病病毒感染者/病人生存质量在生理职能、躯体疼痛以及情感职能方面的得分低于常模,在精力方面的得分高于常模;社会支持与健康状况、精力、情感职能和社会功能呈明显正相关;艾滋病病毒感染者/病人回避应对方式与屈服应对方式得分高于常模水平;面对应对方式与精神健康和情感职能呈正相关;屈服应对方式与生理机能、健康状况、精力和精神健康呈负相关。结论应该对艾滋病病毒感染者/病人开展心理健康教育,帮助艾滋病病毒感染者/病人充分利用社会支持,提高其生存质量;同时鼓励艾滋病病毒感染者/病人采用更加积极的应对方式来面对疾病带来的痛苦,更好的生活下去。     

急救医学新模式新技术的研究与影视录像制作

目的探索急救医疗服务体系建设及运行的有效模式,创作急救医学影视教材,提高急救医疗质量和水平。方法（1）对国内外急救医疗体系的建设与发展进行调研、分析,总结特点,积累资料;（2）充分利用有效资源,创建急救医学运行模式;（3）制作现代急救医学影视教材;（4）运用实践。结果按新模式运行后各急救医疗指标均明显提高。结论该项目成果能规范急救医疗服务行为,提高急救效能,提高对危重患者救治和对突发公共卫生事件及灾害事故的应对能力和水平,具有可推广性。     

上海市某区域医疗就诊行为与流向调查

目的探讨我国政府通过引导病人就诊流向以缓解“看病难”、“看病贵”问题的可能性。方法对上海市某区的1所二级甲等中心医院和其周围的4个社区卫生服务中心以及其所在街道的病人和社区居民进行问卷调查，分析社区居民和医院病人的就诊行为和流向。结果经常在社区卫生服务中心、二级医院和三级医院就诊的居民分别占43．19％、36．86％和17．47％，门诊诊疗费对社区居民门诊流向有较大影响。结论门诊病人的流向具有可引导性。政府应采取措施引导病人的就诊流向，以缓解“看病难”、“看病贵”问题。     

Modeling emotion and behavior in animated personas to facilitate human behavior change: the case of the HEART-SENSE game

The goal of this research is to determine whether a computer based training game (HEART-SENSE) can improve recognition of heart attack symptoms and shift behavioral issues so as to reduce pre-hospitalization delay in seeking treatment. Since treatment delay correlates with adverse outcomes, this research could reduce myocardial infarction mortality and morbidity. In Phase I we created and evaluated a prototype virtual village in which users encounter and help convince synthetic personas to deal appropriately with a variety of heart attack scenarios and delay issues. Innovations made here are: (1) a design for a generic simulator package for promoting health behavior shifts, and (2) algorithms for animated pedagogical agents to reason about how their emotional state ties to patient condition and user progress. Initial results show that users of the game exhibit a significant shift in intention to call 9-1-1 and avoid delay, that multi-media versions of the game foster vividness and memory retention as well as a better understanding of both symptoms and of the need to manage time during a heart attack event. Also, results provide insight into areas where emotive pedagogical agents help and hinder user performance. Finally, we conclude with next steps that will help improve the game and the field of pedagogical agents and tools for simulated worlds for healthcare education and promotion.     

Competition in the off-patent medicine market in Spain: The national reference pricing system versus the regional system of tendering for outpatient prescription medicines in Andalusia

Spain has a reference price system (RPS) for off-patent medicines since 1997. In addition, from 2012, Andalusia is running a series of tenders for procuring off-patent medicines dispensed by community pharmacies, for those medicines included in the system of homogenous clusters within the national reference price system. Such tenders offer additional savings to the regional payer – in the form of rebates (“economic improvements”) from companies winning the tender. This paper estimates that the regional savings were between €43 M to €54 M over the period of study (April – September 2015). The paper also estimates that Spain could have made between 14 and 17 times higher savings than the national reference pricing system savings, had the Andalusian-type tender been implemented at national level over the same period of study. Based on our analysis, we have four remarks. First, the national RPS in Spain is not generating enough price competition for off-patent products dispensed in primary care pharmacies. Second, tenders can be a useful way to generate competition and financial savings in the off-patent market. Third, tenders can lead to discounts offered by medicine providers being redistributed from pharmacies to payers. And fourth, before implementing a national tender in Spain, several key issues need to be addressed to ensure it provides the right incentives both in the short and long run.     

定点医疗管理下的门诊服务利用与费用分析：以杭州A医院为例

目的：探讨定点医疗管理对参保人员门诊服务利用的影响。方法：采用Excel2003和SPSS12．0对数据进行分析。结果：2007年上半年门诊两周就诊率呈逐月上升趋势,下半年基本维持在60．0％。左右;各月医保基金支付额占门诊医疗费的比重呈“U”型分布,门诊次均费用逐月上升,下半年增长迅速;次均费用、两周就诊率与统筹基金支付比重有相关关系。结论：定点医疗管理办法提高了居民的门诊服务利用水平,减轻了患者的疾病经济负担,提高了医保基金的使用效率。     

基层医疗卫生机构药品供应现状及短缺因素分析——以安徽省为例

目的:以安徽省为例,了解基层医疗卫生机构的药品供应现状及药品短缺因素。方法:以安徽省基层医疗卫生机构为主要调查对象,通过分层随机抽样在皖北、皖中、皖南三个地区共抽取106家基层医疗卫生机构;并同时以方便抽样的方式抽取54家药品生产企业和62家药品经营企业;发放问卷了解基层医疗卫生机构的药品供应现状及造成药品短缺的主要原因和解决方法。结果:样本地区仍有13%的基层医疗卫生机构存在药品供应严重不足的现象;各个单位的药品配送率存在较大差异,有19%的基层医疗卫生机构药品配送率在70%以下;调查范围内的全部基层医疗卫生机构存在或者经历过药品短缺。导致药品短缺的主要原因有药品需求不稳定(19.20%)、药品有新的且利润较高替代品(15.94%)等;药品短缺的解决措施包括完善国家基本药物目录(12.78%),适当提高疗效确切、价格低廉品种价格(12.03%)等。结论:基层医疗卫生机构存在药品短缺现象,原因较为复杂;政府应继续推行相关政策,全面改善基层医疗卫生机构药品供应现状,防范药品短缺。     

广东省欠发达地区新农合实施情况评价研究

文章抽取广东省欠发达地区两个贫困县为调查对象,通过自行设计调查问卷,对韶关市、清远市某贫困县19个行政村292户农民进行实地调查。调查采取走村人户、深入访谈与问卷调查相结合的形式,了解当地新农合实施情况以及农民对新农合的认知程度与满意度,并对新农合的实施现状及效果做了初步分析评价。该研究在广东省基本实现农村合作医疗全覆盖形势下,提供了欠发达地区实施效果研究的实证依据。     

Drug promotional activities in Nigeria: impact on the prescribing patterns and practices of medical practitioners and the implications

Objective: Pharmaceutical companies spend significant amount of resources on promotion influencing the prescribing behavior of physicians. Drug promotion can negatively impact on rational prescribing, which may adversely affect the quality of patient care. However, little is known about these activities in Nigeria as the most populous country in Africa. We therefore aimed to explore the nature of encounters between Nigerian physicians and pharmaceutical sales representatives (PSRs), and how these encounters influence prescribing habits.

Methods: Cross-sectional questionnaire-based study conducted among practicing physicians working in tertiary hospitals in four regions of Nigeria.

Results: 176 questionnaires were completed. 154 respondents (87.5%) had medicines promoted to them in the previous three months, with most encounters taking place in outpatients’ clinics (60.2%), clinical meetings (46%) and new medicine launches (17.6%). Information about potential adverse effects and drug interactions was provided in 41.5%, and 27.3% of cases, respectively. Food, in the form of lunch or dinner, was the most common form of incentive (70.5%) given to physicians during promotional activities. 61% of physicians felt motivated to prescribe the drug promoted to them, with the quality of information provided being the driving factor. Most physicians (64.8%) would agree to some form of regulation of the relationship between medical doctors and the pharmaceutical industry.

Conclusion: Interaction between PSRs and physicians is a regular occurrence in Nigeria, influencing prescribing practices. Meals and cheap gifts were the most common items offered to physicians during their encounters with PSRs. The need for some form of regulation by professional organizations and the government was expressed by most respondents to address current concerns.     

How the organisation of medical work shapes the everyday work experiences underpinning doctor migration trends: The case of Irish-trained emigrant doctors in Australia

Medical migration is a global phenomenon. In Ireland, hospital doctor emigration has increased significantly in recent years, with Australia a destination of choice. With work and employment conditions cited as a driver of these trends, this article explores how health system differences in the organisation of medical work shape the everyday experiences of hospital doctors which underpin migration decisions. Drawing on 51 semi-structured interviews conducted in July-August 2018 with Irish-trained hospital doctors who had emigrated to work in Australia, the findings highlight doctors’ contrasting experiences of medical work in the Irish and Australian health systems. Key system differences in the organisation of medical work manifested at hospital level and related to medical hierarchy; staffing, support and supervision; and governance and task coordination. Findings indicate that retention of hospital doctors is as much about the quality of the work experience, as it is about the quantity and composition of the workforce. At a time of international competition for medical staff, effective policy for the retention of hospital doctors requires an understanding of the organisation of work within health systems. Crucially, this can create working contexts in which doctors flourish or from which they seek an escape.     

住院患者对医生的信任水平及自我效能与医疗决策行为的关系研究——以医患互动为中介

目的：通过调查杭州市住院患者参与医疗决策行为现状,分析其主要影响因素和机制,为提高杭州市住院患者参与医疗决策积极性、有效性提出建议。方法：采用分层随机抽样的方法,参考成熟量表后自行设计的调查问卷,对杭州市二、三级医院的750名住院患者进行调查;用结构方程模型分析住院患者对医生的信任水平、参与决策自我效能、医患互动与其参与医疗决策行为的作用机制。结果：不同家庭月收入、住院科室、过去一年住院次数、本次入院决策方案制定方式的患者参与医疗决策行为得分有显著性差异(均P＜0.05)。患者参与医疗决策行为与其对医生的信任水平呈负相关;与其自我效能和医患互动呈正相关(P＜0.01)。患者对医生的信任水平和自我效能直接影响患者参与医疗决策行为,直接效应值分别为-0.373、0.358(P<0.001);医患互动在对医生的信任水平、自我效能与患者参与医疗决策行为之间的关系中起较显著的中介作用,中介效应值分别为-0.089、0.328(P<0.001)。结论：医患互动的中介效应可以促进患者参与医疗决策行为的积极性和有效性,医疗卫生机构应以患者为中心,优化住院患者参与医疗决策的途径,加强对医务人员医患互动能力和意识的培训,切实提高患者参与医疗决策行为的主动性和有效性。     

Distancing the mad: Jarvis's Law and the spatial distribution of admissions to the Hamilton Lunatic Asylum in Canada, 1876-1902

The institutional confinement of the 'insane' in the nineteenth century constitutes one of the most controversial events in the social history of medicine. Within this scholarship there has emerged an important debate over the spatial determinants of institutionalization. Some studies uphold an historical postulate--Jarvis's Law--that contends there was a 'distance decay' effect in mental hospital utilization--that is, an inverse correlation between the distance from a medical institution and the likelihood of people to use its resources. Other scholars have challenged or modified this thesis, arguing that factors such as the local politics, urban living, or socio-economic status were more important determinants of institutional confinement. This article contributes to this ongoing debate by analysing over 4000 admissions to the Ontario Provincial Asylum in the city of Hamilton, Canada, between 1876 and 1902. The results confirm Jarvis' Law was applicable to the Hamilton context: there was an inverse statistical relationship between physical distance from the asylum and the likelihood of admission. However, this paper yields three additional dimensions to the literature: (1) it demonstrates that jails were much more likely to be utilized as temporary places of confinement for communities far from provincial mental hospitals; (2) the length of stay in the asylum was positively correlated with the distance travelled to the institution; and (3) an inverse relationship was found when correlating distance from the asylum and the likelihood of being readmitted to the same institution. These findings suggest an impact of 'distance' beyond the dimension of hospital utilization and imply that the broader asylum experience could be affected by the previous location of patients.     

Using multilevel models to evaluate the influence of contextual factors on HIV/AIDS,sexually transmitted infections,and risky sexual behavior in sub-Saharan Africa: a systematic review

Purpose

To describe the use of multilevel models (MLMs) in evaluating the influence of contextual factors on HIV/AIDS, sexually transmitted infections (STIs), and risky sexual behavior (RSB) in sub-Saharan Africa.

在线医疗社区医患互动行为的实证研究——以好大夫在线为例

目的:在线医疗社区是互联网信息技术与医疗服务业结合产生的新兴业态,通过分析我国在线医疗社区发展现状,提出促进互联网技术与传统医疗服务快速融合的政策建议。方法:抓取好大夫在线平台上北京市166家医院,12 497位开通个人网页医生信息进行实证分析,从医生活跃度、患者访问量、患者满意度等方面进行分析。结果:好大夫在线平台上提供的医生、医院资源以公立三级医院为主,医生职称以中级、副高级为主,开通个人主页的医生中只有三分之一具有较高活跃度,平台患者满意度评分较高。结论:在线医疗社区在我国已具备一定规模,并开始逐步影响改变传统医疗服务体系的就医模式,但数据的有效性和与医改的深入结合是决定其发展前景的重要因素。