整体护理结合孕期保健对提高产科护理质量的影响分析

目的：研究整体护理对提高产科护理满意度的影响。方法：选取2013年4-9月在本院分娩的80例产妇,按照随机数字表法将其分为对照组和观察组各40例。对照组给予产科常规护理,观察组在常规护理的基础上定时授课进行孕期健康宣教,产期进行整体护理,观察并比较产妇妊娠期糖尿病（GDM）发生率、孕期保健知识掌握率、护理满意度、住院周期、SAS（Zung焦虑自评量表）评分和SDS（抑郁自评量表）评分。结果：观察组的妊娠合并症发生率为5.0%（2/40）,对照组的妊娠合并症发生率为15.0%（6/40）,比较差异无统计学意义（P〉0.05）;而观察组对孕期保健知识掌握率82.5%明显高于对照组的60.0%,且产妇对护理工作的满意率92.5%明显高于对照组的72.5%,差异均有统计学意义（P〈0.05）。观察组住院周期（4.15±0.95）d明显短于对照组的（4.72±1.30）d,且SAS和SDS评分分别为（45.35±1.66）分、（46.35±1.61）分,均明显低于对照组的（46.13±1.74）分和（47.18±1.97）分,差异均有统计学意义（P〈0.05）。结论：整体护理可以缩短住院周期,改善SAS评分及SDS评分,明显提高产妇保健知识掌握率及对产科护理的满意度,值得在临床上推广。     

优质护理在提高产科服务质量中的应用

目的 探讨优质护理在提高产科服务质量中的效果.方法 以我院2012年1月至2013年1月间收治的200例产妇为研究对象,按入院时间,将研究对象分为观察组（2012年7月至2013年1月,100例）与对照组（2012年1月至2012年6月,100例）.所有产妇均行基础治疗与护理,观察组产妇在此基础上增加优质护理服务,比较两组产妇的心理症状水平、健康教育效果、生活质量和护理服务满意度.结果 观察组产妇心理症状水平低于对照组,健康教育效果、生活质量和护理服务满意度高于对照组,其差异有统计学意义（P均＜0.05）.结论 优质护理可以有效提高产科服务质量,降低产妇心理症状水平,增强健康教育效果,改善产妇生活质量,提高产妇护理服务满意度.     

Changes in Quality of Health Care Delivery after Vertical Integration

ObjectivesTo fill an empirical gap in the literature by examining changes in quality of care measures occurring when multispecialty clinic systems were acquired by hospital-owned, vertically integrated health care delivery systems in the Twin Cities area.ConclusionsMoving a clinic system into a vertically integrated delivery system resulted in limited increases in quality of care indicators. Caution is warranted when the acquisition causes disruption in referral patterns.     

Availability and Primary Health Care Orientation of Dementia-Related Services in Rural Saskatchewan,Canada

Community-based services are important for improving outcomes for individuals with dementia and their caregivers. This study examined: (a) availability of rural dementia-related services in the Canadian province of Saskatchewan, and (b) orientation of services toward six key attributes of primary health care (i.e., information/education, accessibility, population orientation, coordinated care, comprehensiveness, quality of care). Data were collected from 71 rural Home Care Assessors via cross-sectional survey. Basic health services were available in most communities (e.g., pharmacists, family physicians, palliative care, adult day programs, home care, long-term care facilities). Dementia-specific services typically were unavailable (e.g., health promotion, counseling, caregiver support groups, transportation, week-end/night respite). Mean scores on the primary health care orientation scales were low (range 12.4 to 17.5/25). Specific services to address needs of rural individuals with dementia and their caregivers are limited in availability and fit with primary health care attributes.     

How Health Care Complexity Leads to Cooperation and Affects the Autonomy of Health Care Professionals

Health professionals increasingly face patients with complex health problems and this pressurizes them to cooperate. The authors have analyzed how the complexity of health care problems relates to two types of cooperation: consultation and multidisciplinary teamwork (MTW). Moreover, they have analyzed the impact of these two types of cooperation on perceived professional autonomy. Two teams were studied, one team dealing with geriatric patients and another treating oncology patients. The authors conducted semi-structured interviews, studied written documents, held informal discussions and observed the teams at work. Consultation was most likely to take place when a patient had multiple problems. However, if these problems were interrelated, i.e. the solution for one problem interfered with solving another, then MTW was favored. The same was true when the available information was equivocal such that there were conflicting interpretations of a problem. How the professionals perceived the relationship between complexity and the need to cooperate depended on their expertise, their occupational background, and their work orientation. Consultation did not affect the professional autonomy of the health care professionals. MTW however did decrease the perceived level of professional autonomy. The extent to which this occurred seemed to depend on the quality of the interpersonal relations within the team. The findings can help in selecting the most appropriate and efficient type of cooperation based on the complexity of a patient’s problems. They can also help team leaders to stimulate reflection and feedback processes, and medical trainers to develop competencies among students related to such teamwork behaviors.     

Availability, Utilisation and Quality of Basic and Comprehensive Emergency Obstetric Care Services in Malawi

Objective To establish a baseline for the availability, utilisation and quality of maternal and neonatal health care services for monitoring and evaluation of a maternal and neonatal morbidity/mortality reduction programme in three districts in the Central Region of Malawi. Methods Survey of all the 73 health facilities (13 hospitals and 60 health centres) that provide maternity services in the three districts (population, 2,812,183). Results There were 1.6 comprehensive emergency obstetric care (CEmOC) facilities per 500,000 population and 0.8 basic emergency obstetric care (BEmOC) facilities per 125,000 population. About 23% of deliveries were conducted in emergency obstetric care (EmOC) facilities and the met need for emergency obstetric complications was 20.7%. The case fatality rate for emergency obstetric complications treated in health facilities was 2.0%. Up to 86.7% of pregnant women attended antenatal clinic at least once and only 12.0% of them attend postnatal clinic at least once. There is a shortage of qualified staff and unequal distribution with more staff in hospitals leaving health centres severely understaffed. Conclusions The total number of CEmOC facilities is adequate but the distribution is unequal, leaving some rural areas with poor access to CEmOC services. There are no functional BEmOC facilities in the three districts. In order to reduce maternal mortality in Malawi and countries with similar socio-economic profile, there is a need to upgrade some health facilities to at least BEmOC level by training staff and providing equipment and supplies.     

States’ Experiences With Loan Repayment Programs for Health Care Professionals in a Time of State Budget Cuts and NHSC Expansion

Purpose: The landscape of education loan repayment programs for health care professionals has been turbulent in recent years, with doubling of the funding for the National Health Service Corps (NHSC) and cuts in funding for some states’ programs. We sought to understand how this turbulence is being felt within the state offices involved in recruiting clinicians to rural and urban underserved communities. Methods: We conducted key informant telephone interviews with staff of state offices of rural health, primary care organizations, and/or related organizations within 28 diverse states to answer questions about perceived changes and interplay among solely state‐funded loan repayment programs, joint state‐federal programs, and the NHSC federal program. Interviews were transcribed, formally analyzed, and key issues summarized. Findings: Informants reported that solely state‐funded and joint state‐federal loan repayment programs are greatly valued for their ability to target a state's particular needs and to complement the NHSC federal program. However, budgets for state programs have been threatened, reduced, or eliminated entirely in many cases. All informants positively perceived the NHSC's recent growth and changes, which they feel are helping fill important workforce needs for their states. Nevertheless, the much larger NHSC federal program now competes with some states’ programs for clinicians and service sites; states’ programs are pushed to adjust their operations to maintain a unique “niche.” Conclusions: States’ key recruiters lament reductions in funding for states’ loan repayment programs, and welcome the NHSC's recent growth and changes. Better coordination is needed to minimize competition and maximize complementarity between state and federal programs.     

Providing Comprehensive Sexual Health Care in Spinal Cord Injury Rehabilitation: Implementation and Evaluation of a New Curriculum for Health Care Professionals

A grant from the Paralyzed Veterans of America funded the development, implementation, and evaluation of a three-day interdisciplinary continuing education and training program in comprehensive sexual health care. The program was targeted toward health care professionals working in spinal cord injury (SCI) rehabilitation. The major goal of the program was to offer participants an opportunity to increase the knowledge, comfort, and skills necessary to understand and manage the sexual health care needs of people with SCI. The curriculum included clearly stated goals, behavioral objectives in operational terms, and multiple quantitative and qualitative program evaluations. In addition, the comprehensive curriculum incorporated extensive skills training including state-of-the-art standardized patient training techniques. Evaluation results indicated statistically significant and qualitatively important positive gains in knowledge, comfort, and skills. The five month follow-up study indicated that skills learned over the three-day workshop were successfully transferred to the work environment.     

Risk Factors for Late or No Prenatal Care Following Medicaid Expansions in California

Objectives: To describe the characteristics and risk factors of women with only third-trimester (late) or no prenatal care. Methods: A statewide postpartum survey was conducted that included 6364 low-income women delivering in California hospitals in 1994 and 1995. Results: The following factors appeared most important, considering both prevalence and association with late or no care: poverty, being uninsured, multiparity, being unmarried, and unplanned pregnancy. Forty-two percent of women with no care were uninsured, and uninsured women were at dramatically increased risk of no care. Over 40% of uninsured women with no care had applied for Medi-Cal prenatally but did not receive it. Risks did not vary by ethnicity except that African American women were at lower risk of late care than women of European background. Child care problems were not significantly associated with either late or no care, and transportation problems (not asked of women with no care) were not significantly related to late care. Conclusions: Lack of insurance appeared to be a significant barrier for the 40% of women with no care who unsuccessfully applied for Medi-Cal prenatally, indicating a need to address barriers to Medi-Cal enrollment. However, lack of financial access is unlikely to completely explain the dramatic risks associated with being uninsured. In addition to eliminating barriers to prenatal coverage, policies to reduce late/no care should focus on pre-pregnancy factors (e.g., planned pregnancy and poverty reduction) rather than on logistical barriers during pregnancy.Dr. Nothnagle was a medical student at the University of California, San Francisco when most of the work for this study was done     

正常分娩综合性实验在产科护理教学中的应用研究

目的探讨在产科护理教学中应用正常分娩综合性实验教学取得的效果研究。方法选取2018年9月—2019年6月在该院实习120名护理本科生作为研究对象,依据奇数偶数分配原则分为两组,其中对照组60名学生进行常规的消毒操作和外阴清洁考核,观察组的60名学生应用正常分娩综合性实验进行考核,对比两组学生护理技能测试成绩以及取得的教学效果。结果观察组优良率(98.33%)高于对照组(88.33%),差异有统计学意义(P<0.05);观察组团队协作能力、学习兴趣、解决问题能力、沟通能力及操作能力评分高于对照组,差异有统计学意义(P<0.05)。结论产科护理教学中应用正常分娩综合性实验教学取得的效果显著,能提升教学成绩,让实习护理本科生更快掌握护理技巧,为医院输送优质护理人才,能缓解产科护理人员缺乏的现象,正常分娩综合性实验教学方案值得应用。     

Alternative Measures of Spatial Distribution and Availability of Health Facilities for the Delivery of Emergency Obstetric Services in Island Communities

International guidelines and recommendations for availability and spatial distribution of emergency obstetric care services do not adequately address the challenges of providing emergency health services in island communities. The isolation and small population sizes that are typical of islands and remote populations limit the applicability of international guidelines in such communities. Universal access to emergency obstetric care services, when pregnant women encounter complications, is one of the three key strategies for reducing maternal and newborn mortality; the other two being family planning and skilled care during labor. The performance of selected lifesaving clinical interventions (signal functions) over a 3-month period is commonly used to assess and assign performance categories to health facilities but island communities might not have a large enough population to generate demand for all the signal functions over a 3-month period. Similarly, availability and spatial distribution recommendations are typically based on the size of catchment populations, but the populations of island communities tend to be sparsely distributed. With illustrations from six South Pacific Island states, we argue that the recommendation for availability of health facilities, that there should be at least five emergency obstetric care facilities (including at least one comprehensive facility) for every 500,000 population, and the recommendation for equitable distribution of health facilities, that all subnational areas meet the availability recommendation, can be substituted with a focus on access to blood transfusion and obstetric surgical care within 2 hours for all pregnant residents of islands. Island communities could replace the performance of signal functions over a 3-month period with a demonstrated capacity to perform signal functions if the need arises.     

产科住院患者抗菌药物合理使用的管理对策

目的探究产科住院患者抗菌药物合理使用的管理对策。方法选取790例在2017年1月-2018年1月管理对策实施前该院产科收治的患者(对照组)和790例在2018年2月-2019年2月管理对策实施后该院产科收治的患者(观察组)。对产科住院患者抗菌药物的不合理使用进行总结分析,并采取有效的管理对策。统计分析两组患者术后感染发生率情况。结果与对照组(2.53%)相比,观察组患者术后感染发生率(0.63%)较低(χ^2=11.285,P<0.05)。结论通过对产科进行积极整改和专项调研,实行专项处方点评制度、分级管理制度,强化对相关人员的知识培训,能够促进产科抗菌药物的使用合理性明显改善,降低患者术后感染发生率。同时,通过持续改进管理体制,有利于产科在使用抗菌药物过程中更加合理化和规范化。     

Access to Health Care in the Scandinavian Countries: Ethical Aspects

The health care systems are fairly similar in theScandinavian countries. The exact details vary, but inall three countries the system is almost exclusivelypublicly funded through taxation, and most (or all)hospitals are also publicly owned and managed. Thecountries also have a fairly strong primary caresector (even though it varies between the countries),with family physicians to various degrees acting asgatekeepers to specialist services. In Denmark most ofthe GP services are free. For the patient in Norwayand Sweden there are out-of-pocket co-payments for GPconsultations, with upper limits, but consultations forchildren are free. Hospital treatment is free inDenmark while the other countries use a system without-of-pocket co-payment. There is a very strongpublic commitment to access to high quality healthcare for all. Solidarity and equality form theideological basis for the Scandinavian welfare state.Means testing, for instance, has been widely rejectedin the Scandinavian countries on the grounds thatpublic services should not stigmatise any particulargroup. Solidarity also means devoting specialconsideration to the needs of those who have lesschance than others of making their voices heard orexercising their rights. Issues of limited access arenow, however, challenging the thinking about a healthcare system based on solidarity.     

The Financial Implications of Availability and Quality of a Usual Source of Care for Children with Special Health Care Needs

Objective To examine the relationship of availability and quality of a usual source of care (USC) to medical expenditures overall and for various types of health care services for children with special health care needs (CSHCN), as a group and by four diagnostic subgroups (asthma, non-asthmatic physical conditions, mental retardation, other mental illnesses). Methods Generalized linear models were used to estimate the annual average per capita medical expenditures (APCME) based on data from 820 CSHCN in the 1995 National Health Interview Survey on Disability and 1996 Medical Expenditure Panel Survey. Results In 1996, 92% of non-institutionalized CSHCN in the United States had a USC. Of these, 52% were classified as receiving accessible care, 95% received comprehensive care, and 69% received satisfactory care. Approximately 89% of CSHCN had expenditures on health care in 1996 and the APCME was $1,344 for CSHCN as a group. Having a USC was associated with higher expenditures overall and for almost all types of health care services for CSHCN across conditions. Receiving comprehensive care was associated with lower total medical expenditures for CSHCN with asthma, whereas receiving satisfactory care was associated with higher total medical expenditures for CSHCN with non-asthma physical conditions. Conclusion Having a regular care provider is associated with higher expenditures for CSHCN across diagnosis. Among CSHCN with a USC, quality of care is associated with medical expenditures, although specific associations vary by the quality characteristic and the condition of the child. These results may mask heterogeneity in severity of condition and quality of care over time.     

Measuring the Quality of a Childhood Cancer Care Delivery System: Quality Indicator Development

ObjectivesA set of indicators to assess the quality of a childhood cancer system has not been identified in any jurisdiction internationally, despite the movement toward increased accountability and provision of high-quality care with limited health care resources. This study was conducted to develop a set of quality indicators (QIs) of a childhood cancer control and health care delivery system in Ontario, Canada.MethodsA systematic review and targeted gray literature search were conducted to identify potential childhood cancer QIs. A series of investigator focus group sessions followed to review all QIs identified in the literature, and to generate a provisional QI set for a childhood cancer system. QIs were evaluated by three content experts in a sequential selection process on the basis of a series of criteria to select a subset for presentation to stakeholders. Following an appraisal of the relevance of quality assessment frameworks, remaining QIs were mapped onto the Cancer System Quality Index framework.ResultsThe systematic review yielded few relevant childhood cancer system QIs. Overall, 120 provisional QIs were developed by the investigator group. Based on median QI rating scores, representation across the childhood cancer continuum, and feasibility of data collection, a subset of 33 QIs was selected for stakeholder consideration.ConclusionsThe subset of 33 QIs developed on the basis of a systematic literature review and consensus provides the basis for the selection of a set of QIs for ongoing, standardized monitoring of various dimensions of quality in a childhood cancer system.     

Acceptance of New Medicaid Patients by Primary Care Physicians and Experiences with Physician Availability among Children on Medicaid or the Children's Health Insurance Program

Objective

To estimate the relationship between physicians'' acceptance of new Medicaid patients and access to health care.

Data Sources

The National Ambulatory Medical Care Survey (NAMCS) Electronic Health Records Survey and the National Health Interview Survey (NHIS) 2011/2012.

Study Design

Linear probability models estimated the relationship between measures of experiences with physician availability among children on Medicaid or the Children''s Health Insurance Program (CHIP) from the NHIS and state-level estimates of the percent of primary care physicians accepting new Medicaid patients from the NAMCS, controlling for other factors.

Principal Findings

Nearly 16 percent of children with a significant health condition or development delay had a doctor''s office or clinic indicate that the child''s health insurance was not accepted in states with less than 60 percent of physicians accepting new Medicaid patients, compared to less than 4 percent in states with at least 75 percent of physicians accepting new Medicaid patients. Adjusted estimates and estimates for other measures of access to care were similar.

Conclusions

Measures of experiences with physician availability for children on Medicaid/CHIP were generally good, though better in states where more primary care physicians accepted new Medicaid patients.     

Method to Develop Health Care Peer Groups for Quality and Financial Comparisons Across Hospitals

Objective. To develop and explore the characteristics of a novel "nearest neighbor" methodology for creating peer groups for health care facilities.
Data Sources. Data were obtained from the Department of Veterans Affairs (VA) databases.
Statistical Methods and Findings. Peer groups are developed by first calculating the multidimensional Euclidean distance between each of 133 VA medical centers based on 16 facility characteristics. Each medical center then serves as the center for its own peer group, and the nearest neighbor facilities in terms of Euclidean distance comprise the peer facilities. We explore the attributes and characteristics of the nearest neighbor peer groupings. In addition, we construct standard cluster analysis-derived peer groups and compare the characteristics of groupings from the two methodologies.
Conclusions. The novel peer group methodology presented here results in groups where each medical center is at the center of its own peer group. Possible advantages over other peer group methodologies are that facilities are never on the "edge" of a group and group size—and thus group dispersion—is determined by the researcher. Peer groups with these characteristics may be more appealing to some researchers and administrators than standard cluster analysis and may thus strengthen organizational buy-in for financial and quality comparisons.