荆州市9年妊高征妇女死亡相关因素分析

１９９０～１９９８ 年间，荆州市活产总数８０３ ５１７ 例，其中因妊高征死亡者３４ 例，占死亡总数的１３３３％ ，居荆州市孕产妇死亡原因顺位的第２ 位。妊高征死亡专率为４２３／１０ 万。其死亡的主要原因是脑血管病、脑水肿和心力衰竭，两者共占７０６１％ 。资料分析表明，个人家庭卫生知识贫乏和医疗保健系统中工作人员知识技能不足是影响妊高征死亡的主要因素。加强孕期保健，认真监测妊高征 ３ 大症状与体征，提高产科门诊质量，合理使用硫酸镁和降压药，防止脑血管意外，适时终止妊娠，是降低妊高征死亡率的关键。     

Perception of primary care physicians on the impact of comprehensive geriatric assessment: what is the next step?

Older adults are at high risk of developing multimorbidity, and the high levels of clinical and psychosocial complexity in this population pose special challenges for primary care physicians (PCPs). As a way to improve the care for the older adults, a number of health systems have developed programs to provide comprehensive geriatric assessment (CGA), which generally refers to an intensive interprofessional evaluation and management of geriatric syndromes with the goals of maximizing health in aging. Sternberg and Bentur examined the impact of CGA as perceived by PCPs, the PCPs attitude toward CGA, and their satisfaction with CGA. In this commentary, we seek to provide additional context to the current state of outpatient consultative CGA and how it relates to the findings in the study by Sternberg and Bentur. The knowledge gained from this study begs for future investigations, especially in the areas of PCPs’ understanding of outpatient consultative CGA, the perceived benefit in health outcomes and actual health outcomes, perceived needs in geriatric consultation, preference in management of complex geriatric syndromes, and interests in continuing education in geriatrics. Insight into these factors could allow for improvement of the current outpatient consultative CGA model and allow for adaption of the model to local needs.     

2003～2005年北京市朝阳区流动人口儿童保健状况

目的:了解北京市朝阳区流动人口的儿童健康状况,为制定流动人口儿童的保健管理模式及健康干预措施提供参考。方法:对2003～2005年北京市朝阳区辖区流动人口儿童的保健资料进行分析。结果:3年间,参加新生儿访视的人数逐年增加,高危儿检出人数增加;流动人口的5岁以下儿童死亡率高于北京市户籍儿童(P<0.05);死因顺位与北京市户籍儿童相同;外地流动儿童保健管理率、系统管理率、儿童大体检率均较北京市户籍儿童低,参加保健的儿童体格发育与北京市户籍儿童相同,但佝偻病、贫血的发病率较户籍儿童高。结论:流动人口儿童参加保健的人数少,系统管理率低,儿童死亡率高,建议将流动人口儿童的保健管理工作作为今后的工作重点,努力降低流动儿童的死亡率。     

Dietary Management of Heart Failure: DASH Diet and Precision Nutrition Perspectives

Heart failure (HF) is a major health care burden increasing in prevalence over time. Effective, evidence-based interventions for HF prevention and management are needed to improve patient longevity, symptom control, and quality of life. Dietary Approaches to Stop Hypertension (DASH) diet interventions can have a positive impact for HF patients. However, the absence of a consensus for comprehensive dietary guidelines and for pragmatic evidence limits the ability of health care providers to implement clinical recommendations. The refinement of medical nutrition therapy through precision nutrition approaches has the potential to reduce the burden of HF, improve clinical care, and meet the needs of diverse patients. The aim of this review is to summarize current evidence related to HF dietary recommendations including DASH diet nutritional interventions and to develop initial recommendations for DASH diet implementation in outpatient HF management. Articles involving human studies were obtained using the following search terms: Dietary Approaches to Stop Hypertension (DASH diet), diet pattern, diet, metabolism, and heart failure. Only full-text articles written in English were included in this review. As DASH nutritional interventions have been proposed, limitations of these studies are the small sample size and non-randomization of interventions, leading to less reliable evidence. Randomized controlled interventions are needed to offer definitive evidence related to the use of the DASH diet in HF management.     

Specialist Nurse-Led Intervention in Outpatients with Congestive Heart Failure

Congestive heart failure (CHF) encompasses a spectrum of clinical syndromes and presentations. It affects 1–2% of the population in the UK and is associated with significant mortality which is comparable to most cancers. It accounts for more than 5% of adult medical admissions in the UK, with significant annual re-admission rates. Improved understanding of the pathophysiology of CHF has resulted in significant advancements in CHF management. Current pharmacologic agents, such as ACE inhibitors, β-adrenoceptor antagonists and spironolactone, influence symptoms and improve mortality. Despite this, many patients still require hospitalization. Multiple, potentially reversible factors are involved which, if addressed effectively, may result in significant reductions in re-admission rates. Patients with CHF often have other conditions, such as respiratory disease, resulting in prolonged lengths of stay. Suboptimal care and failure to adhere to management guidelines is also a preventable cause for re-admission. There has been an increasing need to develop adjunctive, non-pharmacologic strategies for managing CHF, which are designed to improve the patient’s functional status and quality of life. Key elements include systematic follow-up care and patient education. The concept of intensive outpatient or home-based CHF intervention has been developed and extensively evaluated in several randomized controlled trials. Early studies were inconclusive but provided an indication that discharge planning and home-based education are valuable strategies. Recently, an increasing number of studies utilizing the CHF nurse practitioner have provided positive results for non-pharmacologic intervention and demonstrate the potential of these interventions to reduce admissions to hospital by up to 50%. These studies had specific inclusion criteria and could not be generalized to the CHF population as a whole. The Study to Evaluate the effectiveness of Nurse-led Intervention in the management of outpatients with heart Failure (SENIF) explored whether a similar approach to CHF management was beneficial in a typical outpatient population of patients with CHF. Over 12 months, fewer intervention group patients required admission, resulting in 69% fewer hospital days. Cost effectiveness of nurse-led intervention has been suggested in several studies including SENIF, resulting from reduced hospitalizations and re-admissions, which vastly outweighed the modest increase in expenditure required to run the programs. Hospitalizations because of CHF impact greatly on limited healthcare resources. Specialist nurse-led intervention in CHF is a cost-effective, non-pharmacological strategy to help optimize CHF management.     

急性心力衰竭再入院及死亡风险预测模型研究进展

心力衰竭是各种心脏疾病的严重和终末期表现,具有高住院率、高病死率等特点,已成为重要的公共卫生问题。急性心力衰竭患者出院后再入院率及死亡率是评价心力衰竭医疗质量的重要指标,基于此开展急性心力衰竭患者疾病预后风险预测研究,对量化疾病风险、落实分层管理、优化临床决策、提高生存质量、改善患者预后、全面提升我国急性心力衰竭医疗质量至关重要。近20年来,国外学者已开发出数十个急性心力衰竭再入院及死亡风险预测模型,我国学者也开发出了近十个基于中国人群的预测模型,但目前国内指南中尚无推荐使用的急性心力衰竭预后风险预测模型。本文旨在通过介绍国内外主要急性心力衰竭再入院和死亡风险预测模型,重点概述现有模型局限性及今后发展方向,包括整合多源数据、挖掘新兴生物标志物、构建多基因风险评分、优化机器学习方法、推进模型适用性调整及拓宽应用渠道等,以期为国内急性心力衰竭再入院和死亡风险预测模型相关研究提供思路。     

社区人群脑血管病综合防治研究初探

通过在一个2万人口的社区内进行的社区人群脑血管病综合防治研究.探讨了在城市中建立由居民委员会—医院保健科—脑血管病专科门诊组成的三级防治网,对社区人群施行以健康教育和控制高血压为主的脑血管病综合防治措施的必要性和可行性.通过3年的综合防治,社区人群内高血压患病率由17.96%降至13.83%(P<0.01).脑血管病发病率由161/10万降至68/10万,下降了58%.脑血管病死亡率由109/10万降至47/10万,下降了57%.本研究方法可以推广到更大的人群中去进行预防脑血管病.     

Impact of prior and current alcohol use on use of services by patients with depression and chronic medical illnesses.

OBJECTIVE. Alcohol use often co-occurs with other major chronic conditions, but its effect on health care utilization in this context is not understood. This study examines the impact of alcohol consumption on health care use by patients with chronic medical conditions or depression, or both. DATA SOURCES/STUDY SETTING. Data came from the Medical Outcomes Study, an observational study of patients from the offices of general medical providers and mental health specialists in three U.S. cities. STUDY DESIGN. Longitudinal data spanning four years for outpatient general medical visits and outpatient mental health visits were analyzed using a two-part model to assess the impact of alcohol use disorder, problem drinking, and current and past alcohol consumption on health care use by patients, controlling for patient demographics and health status. DATA COLLECTION/EXTRACTION METHODS. Data were collected from 2,546 adult patients with hypertension, diabetes, heart disease (congestive heart failure or myocardial infarction), and/or current major depression or subthreshold depression using periodic, self-report surveys detailing health care utilization and health status information. PRINCIPAL FINDINGS. Current alcohol consumption increases outpatient doctor visits, and problems related to current drinking decrease outpatient mental health visits. CONCLUSIONS. Patterns of alcohol consumption have an impact on both mental health and overall health care use by patients with chronic medical conditions or depression.     

Comprehensive medical rehabilitation in the 1990s: the community integration rehabilitation model

The development of new models of understanding the disabling process, the changing system of financing health care in the United States, and the increasing incidence of disability is challenging rehabilitation to define new models of care delivery. Current models of comprehensive medical rehabilitation include multidisciplinary therapy in inpatient, outpatient, home and community settings. Managed care and the development of capitated funding systems for health care financing will challenge rehabilitation to prevent disability in a population. This article proposes a model system for comprehensive rehabilitation in managed care: the Community Integration Rehabilitation Model. This system advocates the development of a continuum of services including a strong community-based rehabilitation system, that is, a shift in emphasis to expanding opportunities for independent and productive community living as well as management of disease and impairment for individuals with disabilities, and the forging of partnerships between institution-based rehabilitation and its community. Comprehensive rehabilitation is redefined as a continuum of disability prevention and treatment across the lifespan of a population.     

Germany's disease management program: improving outcomes in congestive heart failure

Hospital admissions among patients with congestive heart failure (CHF) are a major contributor to health care costs. A comprehensive disease management program for CHF was developed for private and statutory health insurance companies in order to improve health outcomes and reduce rehospitalization rates and costs. The program comprises care calls, written training material, telemetric monitoring, and health reports. Currently, 909 members from six insurance companies are enrolled. Routine evaluation, based on medical data warehouse software, demonstrates benefits in terms of improved health outcomes and processes of care. Economical evaluation of claims data indicates significant cost savings in a pre/post study design.     

Delayed access to health care and mortality

OBJECTIVE: To measure the relationship between time spent waiting for health care services and patients' mortality. DATA SOURCE: Data on the number of days until the next available appointment at 89 Veterans Affairs (VA) medical centers in 2001 were extracted from a VA administrative database. These facility-level data were merged with individual-level data for a sample of veterans who visited a VA geriatric outpatient clinic in 2001. The merged dataset includes facility-level data on waiting times and individual-level data on demographics, health status (e.g., diagnoses), and mortality. STUDY DESIGN: This was a retrospective observational study using secondary data from administrative sources. The dependent variable was mortality within a 6-month follow-up period. The main explanatory variable of interest was VA facility-level wait times for outpatient visits measured in number of days. Random effects logistic regression models were risk adjusted for prior individual health status and facility-level differences in case mix. PRINCIPAL FINDINGS: Veterans who visited a VA medical center with facility-level wait times of 31 days or more had significantly higher odds of mortality (odds ratio=1.21, p=0.027) compared with veterans who visited a VA medical center with facility-level wait times of <31 days. CONCLUSIONS: Our findings support the largely assumed association between long wait times for outpatient health care and negative health outcomes, such as mortality. Future research should focus on the causes of long waits for health care (e.g., physician reimbursement levels), the consequences of long waits in other populations, and effective policies to decrease long waits for health care services.     

构建基于移动互联网的患者赋能型心衰健康管理平台

目的构建基于移动互联网的患者赋能型心衰健康管理平台,促进心衰患者进行自我管理,改善临床结局。方法开展课题研究型品管圈活动,搜集高质量临床证据,构建患者赋能型心衰健康管理平台,通过平台推广与应用,对心衰患者行为进行干预。结果平台应用后,医护人员心衰知识水平显著提升,心衰患者自我护理能力明显提升,患者再入院率、死亡率明显下降,应用效果良好。结论基于移动互联网的患者赋能型心衰健康管理平台是心衰慢性病管理的有效手段。     

The business concept of leader pricing as applied to heart failure disease management.

The implementation of a disease management approach for patients with heart failure has been promoted as a way to improve outcomes, including a decrease in hospitalizations. However, in the absence of rigorous cost analyses and with revenues limited by professional fees, heart failure disease management programs may appear to operate at a loss. The literature outlining the importance of disease management for patients with heart failure is summarized. We review the limitations of current cost analyses and outline the economic concepts of leader pricing, vertical integration and transaction costs to argue that heart failure disease management programs may provide significant "downstream" revenue for an integrated system of health care delivery in a fee-for-service payment structure, while reducing overall costs of care. Pilot data from a university-based program are used in support of this argument. In addition, the favorable impact on patient satisfaction and loyalty can enhance market share, a vital consideration for all health systems. Options for improving the reputation of heart failure disease management within a health system are suggested. Viewed as a loss leader, disease management provides not only quality care for patients with heart failure but also appears to provide financial benefits to the health system that funds the infrastructure and administration of the program. The actual magnitude of this benefit and the degree to which it mitigates overall administration costs requires further study.     

Why it Pays for Hospitals to Initiate a Heart Failure Disease Management Program

Heart failure is a clinical syndrome usually caused by structural changes in the heart. These changes result in varying degrees of symptomatic functional limitation, typically shortness of breath and fatigue. Heart failure is common, with a lifetime risk for its occurrence in a healthy 40-year-old of 20%. In the US, the cost of heart failure care is now estimated at over $US30 billion annually (year 2007 values).Several forms of treatment have been devised for heart failure: medical, device based, and surgical. These are best individualized to each patient and used in stepped progression to goals that are based on current expert guidelines. When goal-directed treatment is accomplished, three major outcomes are expected: (i) symptom relief and improved quality of life; (ii) a slowing or partial reversal of cardiac structural abnormalities; and (iii) a reduction in mortality.Attempts to deliver care for this complex syndrome have led to the development of heart failure-specific disease management programs. These programs can take different forms. Some involve multi-disciplinary teams that comprise a wide array of specialized physicians, cardiac surgeons, nurses, and other allied health workers, all with specific tasks. Others have a more narrow focus and are nurse-led programs. These programs, when fully implemented, help the patient manage his/her disease more effectively through education about heart failure, the purpose and correct use of medication, and the full utilization of nutritional interventions. These programs are also ideally suited to deliver care for patients with end-stage disease, particularly those needing implantation of left ventricular assist devices or transplantation.When effectively implemented, these programs have been shown to improve quality of life, decrease rate of heart failure hospitalizations, and improve survival compared with usual care. Cost analyses of these programs are challenging, and in the most favorable circumstances the greater up-front cost of more intense care is paid back by a lower rate of utilization of inpatient resources. The details of the University of Wisconsin Program are discussed as an example of a comprehensive management program.     

The impact of an outpatient heart failure clinic on hospital costs and admissions

This study of 216 congestive heart failure (CHF) patients at a large teaching hospital in south-central Ontario was undertaken to determine whether the patients managed in an outpatient heart failure clinic used fewer hospital resources (as expressed in number of admissions, complexity of admission, and length of stay (LOS)) than a matched cohort who were not managed in an outpatient clinic. Statistical significance of LOS opportunities could not be demonstrated (owing to sample size), however, the heart failure clinic is making a positive impact on all types of admissions (CHF and non-CHF) in terms of LOS and suggests that management in an outpatient setting for chronic disease states is important for acute care hospitals to consider.     

妊娠合并心脏病的保健与防治原则探讨

本文阐述了妊娠合并心脏病引起心衰是产科领域和妇幼保健工作的重要课题,加强对患心脏病的孕产妇的孕前、孕期、分娩期及产褥期的保健和治疗,避免其心力衰竭的发生,降低孕产妇的死亡率,是医疗保健的重要内容之一。在妊娠合并心脏病中,以风湿性心脏病占绝大多数。心脏代偿功能在Ⅲ级及以上的孕产妇,心衰的发生率明显增高。本文就5例妊娠合并心脏病的结局,对保健及防治原则进行探讨。     

Outpatient visits after retirement in Europe and the US

I conduct an empirical analysis of the relation between retirement and outpatient care use in Europe and the US, and investigate the potential driving factors of that. I link the empirical analysis to a theoretical model of medical care demand. I document that pensioners tend to visit a doctor with higher probability and more often than the rest of the 50+ population. Ceteris paribus, being retired implies 3–10 % more outpatient visits in Europe. The estimates are of similar magnitude in the US. The paper contributes to the understanding of how population ageing plays a part in the rising health care expenditures. I find evidence that retirement related individual characteristics, increasing leisure time and stronger health preferences all contribute to the positive relation between retirement and outpatient care use, which is mainly driven by the healthier individuals. The gatekeeper role of general practitioners can mitigate the increased demand for outpatient care services after retirement.     

Population impact of stricter adherence to recommendations for pharmacological and lifestyle interventions over one year in patients with coronary heart disease

STUDY OBJECTIVE: To assess the potential number of lives saved associated with the full implementation of aspects of the National Service Framework (NSF) for coronary heart disease (CHD) in England using recently developed population impact measures. DESIGN: Modelling study. SETTING: Primary care. DATA SOURCES: Published data on prevalence of acute myocardial infarction and heart failure, baseline risk of mortality, the relative risk reduction associated with different interventions and the proportion treated, eligible for treatment and adhering to each intervention. MAIN RESULTS: Adopting the NSF recommendations for pharmacological interventions would prevent an extra 1027 (95% CI 418 to 1994) deaths in post-acute myocardial infarction (AMI) patients and an extra 37 899 (95% CI 25 690 to 52 503) deaths in heart failure patients in the first year after diagnosis. Lifestyle based interventions would prevent an extra 848 (95% CI 71 to 1 614) deaths in post-AMI patients and an extra 7249 (95% CI 995 to 16 696) deaths in heart failure patients. CONCLUSIONS: Moving from current to "best" practice as recommended in the NSF will have a much greater impact on one year mortality rates among heart failure patients compared with post-AMI patients. Meeting pharmacological based recommendations for heart failure patients will prevent more deaths than meeting lifestyle based recommendations. Population impact numbers can help communicate the impact on a population of the implementation of guidelines and, when created using local data, could help policy makers assess the local impact of implementing a range of health care targets.     

Allocation of health care resources in the state of Santa Catarina, Brazil: a contribution to a discussion on health financing]

OBJECTIVE: To describe the health situation in municipalities in the state of Santa Catarina, Brazil, in 1996, and to investigate how that correlated with federal health spending in 1997. METHODS: Multiple regression analysis was used to investigate the association between federal health care funding and proportional mortality, supply of health services (hospitals and outpatient clinics), and the municipality's population (number of inhabitants). Also investigated was the association between mortality from broad groups of causes and socioeconomic structure, supply of health services, and the municipality's population. RESULTS: The multiple regression analysis showed an association between proportional mortality due to: 1) infectious diseases and: infant mortality, number of non-doctor medical professionals per 10,000 inhabitants, and number of physicians per 10,000 inhabitants (negative association); 2) chronic degenerative diseases and: percentage of individuals 60 years and older, infant mortality (negative association), and number of non-doctor medical professionals per 10,000 inhabitants (negative association); and 3) external causes of death and: the municipality's population, number of hospitals per 10,000 inhabitants (negative association), and percentage of children younger than 1 year. Health spending per inhabitant in 1997 was mainly associated with the municipality's population, number of outpatient clinics per 10,000 inhabitants, Swaroop and Uemura mortality rate, and deaths due to chronic degenerative diseases in 1996. CONCLUSIONS: Municipalities with a better morbidity and mortality profile and a better health services structure received more federal health care resources. To improve this situation, special strategies should be considered in order to ensure additional resources for municipalities that have poorer health indicators.