综合指数法在评价主诊医师负责制医疗服务质量方面的应用

通过采用综合指数法,对某三级专科医院2008-2011年实行主诊医师负责制后的医疗质量变化情况进行分析,发现医院医疗质量综合指数逐年上升。主诊医师负责制对提高医疗质量能起到较好的促进和推动作用,值得继续深入开展;综合指数评价方法计算简便、结果直观、容易掌握,能为医院管理层提供有力的决策支持。     

主诊医师负责制下教学管理的探讨

目的制订适应主诊医师负责制下的教学管理模式，保证教学质量。结对病区各诊疗小组中有教学资格的带教老师，就完成教学任务的认识和态度及对实习生的素质要求进行了问卷调查。结果在主诊医师负责制下，97．4％的带教老师愿意带教实习生，91．0％带教老师愿意承担教学查房、小讲课等教学任务：对教学医院评估中的一些基本要求如为实习生固定带教老师、固定3～12张分管床位等，百分之六十上的老师认为能做到：科教科每月对诊疗组进行教学任务完成情况考核，有78．5％的带教老师表示赞成。结论在主诊医师负责制下，职能部门通过制订科学的教学考核方法．可以避免在医疗绩效考核为主导下医生重医疗轻教学的影响。     

Solving the COVID-19 Crisis in Post-Acute and Long-Term Care

Our nation's nursing home industry has been in need of overhaul for decades—a situation made all the more evident by COVID-19. AMDA–The Society for Post-Acute and Long-Term Care Medicine is dedicated to quality in post-acute and long-term care process and outcomes. This special article presents 5 keys to solving the COVID-19 crisis in post-acute and long-term care, related to policy, collaboration, individualization, leadership, and reorganization. Taking action during this crisis may prevent sinking back into the complacency and habits of our pre-COVID-19 lives.     

主诊医师负责制的成效与完善

主诊医师负责制近年来逐渐成为国内医院管理领域改革与实践的热点。本文以某军队中心医院为例,对主诊医师负责制推行的具体做法,取得的初步成效和存在的弊端进行阐述,提出推进主诊医师负责制的四点完善措施。     

主诊医师负责制下医疗组管理制度的实施策略与思考

主诊医师下的医疗组是医院医疗管理的最小组织单位。通过对现行医疗组管理制度实施后的效果分析,指出现行医疗组管理存在的问题。并提出在医疗组管理制度实施改革时,应考虑与科主任负责制的协调统一,完善相关人事聘用制度,保证亚专科的发展需求,与医院功能定位相结合,保障疑难危重患者的收治,理性看待人才的合理流动。     

大型综合性医院实施主诊医师负责制的探讨

阐述主诊医师负责制的优势,以及在推行主诊医师负责制的过程中存在的问题,提出主诊医师负责制实施过程中应重点注意的几个问题.     

Post-Acute and Long-Term Care Patients Account for a Disproportionately High Number of Adverse Events in the Emergency Department

ObjectivesHigh rates of adverse events (AEs) are reported for post-acute and long-term care settings (PA/LTC: skilled nursing facilities, inpatient rehabilitation centers, long-term acute care facilities, and home health). However, emergency department (ED)-based studies in this area are lacking. We describe all-cause harm among patients from PA/LTC settings seen in the ED.DesignRetrospective observational study using the ED Trigger Tool, with dual independent nurse reviews of 5582 ED records with triggers (findings increasing the likelihood of an AE) and confirmatory physician review of putative AEs.Setting and ParticipantsWe captured data for all adult patients at an urban, academic ED over a 13-month period (92,859 visits). PA/LTC patients were identified using a computerized ED Trigger Tool and manual review (κ = 0.85).MeasuresWe characterize the AEs identified by severity and type using the ED Taxonomy of Adverse Events, and whether the AE occurred in the ED or was present on arrival. We estimate population AE rates using inverse probability weighting.ResultsCompared with non-PA/LTC patients, PA/LTC patients (4.4% of population; 8.2% of our sample) tended to be older (median age 69 vs 50 years), with comparable sex ratios (54% female overall). PA/LTC patients accounted for 21% of all AEs (26% present on arrival; 13% in ED). Rates of AEs occurring in the ED were comparable after matching on age. Present on arrival AEs from a PA/LTC setting were most commonly related to patient care (39%), medication (34%), and infections (16%).Conclusions and ImplicationsPA/LTC patients account for a small proportion of ED visits but experience a disproportionate number of AEs that are primarily present on arrival and patient-care related, and contribute to an admission rate double that for non-PA/LTC patients. Arguably, this cohort represents PA/LTC patients with the most severe AEs. Understanding these AEs may help identify high-yield targets for quality improvement.     

Effects of Payment Changes on Trends in Post-Acute Care

Objective. To test how the implementation of new Medicare post-acute payment systems affected the use of inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies.
Data Sources. Medicare acute hospital, IRF, and SNF claims; provider of services file; enrollment file; and Area Resource File data.
Study Design. We used multinomial logit models to measure realized access to post-acute care and to predict how access to alternative sites of care changed in response to prospective payment systems.
Data Extraction Methods. A file was constructed linking data for elderly Medicare patients discharged from acute care facilities between 1996 and 2003 with a diagnosis of hip fracture, stroke, or lower extremity joint replacement.
Principal Findings. Although the effects of the payment systems on the use of post-acute care varied, most reduced the use of the site of care they directly affected and boosted the use of alternative sites of care. Payment system changes do not appear to have differentially affected the severely ill.
Conclusions. Payment system incentives play a significant role in determining where Medicare beneficiaries receive their post-acute care. Changing these incentives results in shifting of patients between post-acute sites.     

主诊医师负责制下医院感染管理模式探讨

针对主诊医师负责制医疗改革的举措,医院探索了一套医院感染管理模式和控制方法。通过成立医院感染控制中心,建立绩效考核机制,注重信息化建设和继续教育管理。使医院感染管理得到了持续的改进,降低了医院感染发生率,提高了医疗工作质量和效率。     

Factors Influencing Consumers' Selection of a Primary Care Physician

Abstract

There is a growing body of literature regarding patient choice of health care plans, patient satisfaction, and patient evaluation of health care quality, but there is little information concerning the factors that influence the initial selection of a primary care physician (PCP). This exploratory study identifies and conceptualizes the physician selection dimensions which include: physician reputation/manner, physician record, physician search, consumer self-awareness, physician location, physician qualifications, physician demographics, office atmospherics, house calls/insurance, and valuing patient opinion. The study also develops and tests a scale for PCP selection using factor analysis which is demonstrated to be valid, and determines significant differences of variables, which include education level, gender, and age, using a summated scale. The study is of use to physicians in their targeting and communication strategies, and to researchers seeking to refine the scale.     

Rapid Changes in the Provision of Rehabilitation Care in Post-Acute and Long-Term Care Settings During the COVID-19 Pandemic

ObjectivesLittle is known about how the COVID-19 pandemic has affected rehabilitation care in post-acute and long-term care. As part of a process to assess research priorities, we surveyed professionals in these settings to assess the impact of the pandemic and related research needs.DesignQualitative analysis of open-ended survey results.Setting and Participants30 clinical and administrative staff working in post-acute and long-term care.MethodsFrom June 24 through July 10, 2020, we used professional connections to disseminate an electronic survey to a convenience sample of clinical and administrative staff. We conducted an inductive thematic analysis of the data.ResultsWe identified 4 themes, related to (1) rapid changes in care delivery, (2) negative impact on patients’ motivation and physical function, (3) new access barriers and increased costs, and (4) uncertainty about sustaining changes in delivery and payment. Rapid changes: Respondents described how infection control policies and practices shifted rehabilitation from group sessions and communal gyms to the bedside and telehealth. Negative impact: Respondents felt that patients’ isolation, particularly in residential care settings, affected their motivation for rehabilitation and their physical function. Access and costs: Respondents expressed concerns about increased costs (eg, for personal protective equipment) and decreased patient volume, as well as access issues. Uncertainty: At the same time, respondents described how telehealth and Medicare waivers enabled new ways to connect with patients and wondered whether waivers would be extended after the public health emergency.Conclusions and ImplicationsSurvey results highlight rapid changes to rehabilitation in post-acute and long-term care during the height of the COVID-19 pandemic. Because staff vaccine coverage remains low and patients vulnerable in residential care settings, changes such as infection precautions are likely to persist. Future research should evaluate the impact on care, outcomes, and costs.     

主诊医师负责制对业务收入增长因素分析

目的通过对主诊医师负责制实施前后业务收入的比较,分析主诊医师负责制对医院经济效益和患者收容的影响,探讨完善主诊医师负责制管理体系,促进医院良性发展,降低诊疗费用,减轻患者负担,促进医患和谐。方法资料来源于某院医院信息管理系统,以2006.01—2007.06为前期,2007.07—2008.12为后期。分别对包括门诊量、门诊人均费用、门诊收入、收容量、平均住院日、人均日住院费用、住院收入和业务总收入进行比较和分析。结果业务收入增长主要是收容量、人均日住院费用及门诊人均费用增长所致。结论主诊医师负责制的实施有利于医院的发展,主要是提高了工作人员的积极性、主动性、服务意识,但在一定程度上增加了患者的经济负担。     

Physician Visits and Recognition of Residents' Terminal Phase in Long-Term Care Facilities: Findings From the PACE Cross-Sectional Study in 6 EU Countries

ObjectivesTo describe the relation between physician visits and physicians' recognition of a resident's terminal phase in long-term care facilities (LTCFs) in Belgium, England, Finland, Italy, the Netherlands, and Poland.DesignIn each country, a cross-sectional study was conducted across representative samples of LTCFs. Participating LTCFs reported all deaths of residents in the previous 3 months, and structured questionnaires were sent to several proxy respondents including the treating physician.Setting and Participants1094 residents in 239 LTCFs, about whom 505 physicians returned the questionnaire.MeasuresNumber of physician visits, the resident's main treatment goal, whether physicians recognized the resident's terminal phase and expected the resident's death, and resident and physician characteristics.ResultsThe number of physician visits to residents varied widely between countries, ranging from a median of 15 visits in the last 3 months of life in Poland to 5 in England, and from 4 visits in the last week of life in the Netherlands to 1 in England. Among all countries, physicians from Poland and Italy were least inclined to recognize that the resident was in the terminal phase (63.0% in Poland compared to 80.3% in the Netherlands), and residents in these countries had palliation as main treatment goal the least (31.8% in Italy compared to 92.6% in the Netherlands). Overall however, there were positive associations between the number of physician visits and the recognition of the resident's terminal phase and between the number of physician visits and the resident having palliation as main treatment goal in the last week of life.Conclusions and ImplicationsThis study suggests that LTCFs should be encouraged to work collaboratively with physicians to involve them as much as possible in caring for their residents. Joint working will facilitate the recognition of a resident's terminal phase and the timely provision of palliative care.     

Frailty and Time at Home After Post-Acute Care in Skilled Nursing Facilities

ObjectivesTo examine the association of a claims-based frailty index with time at home, defined as the number of days alive and spent out of hospital or skilled nursing facility (SNF).DesignCohort Study.Setting and ParticipantsA 5% Medicare random sample of fee-for-service beneficiaries, who had continuous part A and B enrollment in the prior 6 months, that were discharged from a short SNF admission in 2014‒2016.MethodsFrailty was measured with a validated claims-based frailty index (CFI) (range: 0‒1, higher scores indicating worse frailty) and categorized into nonfrail (CFI <0.25), mild frailty (CFI 0.25‒0.34), and moderate-to-severe frailty (CFI ≥0.35). We measured home time in the 6 months following SNF discharge (range: 0‒182 days with higher values representing more days at home and thus a better outcome). We used logistic regression to assess the association between frailty and short home time, defined as <173 days, adjusting for age, sex, race, region, a comorbidity index, clinical SNF admission characteristics in the Minimum Data Set, and SNF characteristics.ResultsIn our sample of 144,708 beneficiaries (mean age, 80.8 years, 64.9% female, 85.9% white) who were discharged to community after SNF stay, the mean CFI was 0.26 (standard deviation, 0.07). The mean home time was 165.6 (38.1) days in nonfrail, 154.4 (47.4) days in mild frailty, 145.0 (52.0) days in moderate-to-severe frailty group. After full model adjustments, moderate to severe frailty was associated with a 1.71 (95% CI 1.65‒1.78) higher odds of having short time at home in the 6 months following SNF discharge.Conclusion and ImplicationsHigher CFI is associated with short time at home in Medicare beneficiaries who are discharged to the community after post-acute SNF stay. Our results support the utility of CFI in identifying SNF patients who need additional resources and interventions to prevent health decline and poor quality of life.     

The Macro Impact of Microtransitions in Post-acute and Long-Term Care

The care transitions concept emerged in medical literature more than 40 years ago, with an exponential rise in publications dedicated to its exploration since that time. It is generally accepted that older patients are particularly vulnerable during care transitions because of complex medical comorbidity, frailty, cognitive dysfunction, and the fragmented nature of health care. A care transition is defined as the movement of patients from one health care setting to another as their care needs change during acute or chronic illness. Easily recognizable examples include the discharge of a patient from the hospital to a skilled nursing facility or an admission to the hospital after a patient is evaluated in the emergency department. These macrotransitions are marked by major changes in clinical condition and span days to weeks. This discussion examines a new term coined by the authors: microtransitions, which are care transitions characterized by movement of a patient between health care settings or within a given setting, usually over shorter periods (less than 24 hours) and accompanied by changes in clinical or custodial responsibility for a patient. Although often unrecognized as formal care transitions, these microtransitions, if not handled appropriately, can lead to poor outcomes, including clinical deterioration and the need for macrotransition. The authors propose formal recognition of microtransitions, standardization of processes related to them, and practical considerations for implementation.