标准化病人在医学教育和卫生保健研究中的应用进展

标准化病人(SP)作为许多国家医学教育的标准组成部分,是为医学生和医生提供宝贵临床技能培训和评估机会的专业人员。作者综述了SP在卫生保健领域的应用,并分析了相关优缺点。建议在我国继续深入SP的相关研究,加快建立SP在医学教育和卫生体系应用的正式制度,以提高医疗质量。     

医疗服务质量和费用关系的国际研究综述

医疗服务质量和费用是卫生保健系统经常面临的两个互相竞争的关键要素。医疗费用的不断上涨是否带来质量的提升是不同卫生保健系统共同关注的问题,解决该问题的核心在于了解医疗服务质量和费用之间的关系。本文通过对国外有关质量和费用关系的理论与实践研究进行综述,基于Donabedian结构—过程—结果三维度质量框架进行归纳分析,尝试对目前该主题的研究进展进行系统梳理和展示。研究结果显示,现有研究的分析单位一般基于地区、服务提供者、病人等水平;不同研究所用到的质量指标差异较大;较多研究关注结果质量和费用的关系,而对于结构质量和过程质量与费用关系的研究尚不足;多数研究基于住院环境下,较少研究关注门诊环境,缺乏二者对比的研究。基于现有证据,尚无法对医疗服务质量和费用的关系得出一致的结论,但不同研究所用到的质量指标、数据与方法或局限性等仍值得未来的研究借鉴,以便于更客观合理的对质量和费用关系进行探讨。     

Achieving vocational training goals during six months in an Italian general practice

Background: General practice training in Europe is still an unresolved issue. Italy has developed a formation course similar to specialty schools, awarding a certificate of attendance at the end of a 3-year period. Its training goals are defined mainly as work hours in medical facilities, including two semesters at two general practices.

Objectives: To evaluate if a registrar, during a semester in a general practice, has access to a case spectrum consistent enough to achieve the training goals, both ‘methodological’ (work organization targets) and ‘specific’ (targets of opportunity).

Methods: During a six-month period, every patient contact qualified for tutoring was recorded. For each visit, access mode and priority, patient name, age, patient reason for encounter (RFE), diagnosis, referrals, prescribed laboratory tests and treatment were recorded. Data was evaluated as in other Italian medical specialties; i.e. compared to target numbers.

Results: A total of 1 828 contacts and 2 437 RFE in 122 work days were recorded. There were 1 007 and 613 contacts with and without appointment respectively, 88 ‘family contacts,’ 44 scheduled check-ups, 11 phone contacts, and 65 nurse interventions. Of all contacts, 9.8% were indirect. In six months, we had at least one contact with 792 patients out of 1 500 (52.8%). Main RFE resulted from respiratory and musculoskeletal symptoms while most frequent diagnoses belonged to musculoskeletal, cardiovascular and respiratory fields.

Conclusions: A six months training period can be sufficient for representing a general practitioner's work organization and primary care epidemiology. However, deficiencies were observed.     

2009年中国医疗保障研究综述

2009年以来,我国医疗保障制度建设步伐明显加快,统筹城乡发展,实现全民医保,成为医疗保障政策研究的热点。同时,理论界也开始更多地关注城乡医疗保障的公平性、科学性以及有效性等制度发展的深层次问题。本文从医疗卫生改革与医疗保障、城镇医疗保障、农村医疗保障、城乡医疗救助四个方面综述了2009年以来的相关研究,并地进行了简要评价。     

完善医学教育体系为基层医疗卫生改革提供人才支撑

基层医疗卫生队伍人才缺乏是影响医改正常进行的重要因素。该文针对中国基层医疗人才队伍的基本情况,在深入分析原因后,提出大力发展医学高等教育,是解决基层医疗卫生人才问题,健全基层医疗卫生服务体系的重要支撑,也是实现医改目标的重要举措。     

A review of clinical practice guidelines found that they were often based on evidence of uncertain relevance to primary care patients

ObjectivesPrimary care patients typically have less severe illness than those in hospital and may be overtreated if clinical guideline evidence is inappropriately generalized. We aimed to assess whether guideline recommendations for primary care were based on relevant research.Study Design and SettingLiterature review of all publications cited in support of National Institute for Health and Care Excellence (NICE) recommendations for primary care. The relevance to primary care of all 45 NICE clinical guidelines published in 2010 and 2011, and their recommendations, was assessed by an expert panel.ResultsTwenty-two of 45 NICE clinical guidelines published in 2010 and 2011 were relevant to primary care. These 22 guidelines contained 1,185 recommendations, of which 495 were relevant to primary care, and cited evidence from 1,573 research publications. Of these cited publications, 590 (38%, range by guideline 6–74%) were based on patients typical of primary care.ConclusionNearly two-third (62%) of publications cited to support primary care recommendations were of uncertain relevance to patients in primary care. Guideline development groups should more clearly identify which recommendations are intended for primary care and uncertainties about the relevance of the supporting evidence to primary care patients, to avoid potential overtreatment.     

国际经验对上海医疗体系改革的借鉴与启示

该文介绍了典型的4个国家和地区的医疗体系、卫生筹资和改革过程，借鉴其经验与教训，阐述了其对上海医疗体系改革的启示。     

上海市浦东新区外高桥地区医疗资源整合的实践与探讨

浦东新区外高桥医疗卫生联合体五年运作管理的实践表明,构建医疗联合体对区域医疗资源进行纵向整合,可以优化区域医疗资源配置、提高区域医疗资源使用效率,较好地解决"看病难、看病贵"的现实问题,是对医疗卫生体制改革的有益探索。     

美国退伍军人医疗服务系统改革综述与经验分析

20世纪90年代中后期美国最大的公立医疗体系——退伍军人医疗服务系统进行了全面的改革,并在临床服务、患者满意度、运行效率和费用控制等方面迅速达到行业领先水平。通过对文献的综述和分析,本文认为美国退伍军人医疗服务系统改革的成功有两方面原因：宏观方面,组织结构的区域性整合与按人头支付的方式相结合,产生了加强预防保健和提升医疗质量的激励机制;微观方面,以绩效监测为手段改革管理机制．应用了适应临床需求的信息技术系统,服务重点从专科住院治疗快速转为初级保健。文章还讨论了其对我国公立医院改革的启示：公立医院改革的核心是建立责权统一的管理结构,而非产权变革;进一步整合的组织结构与按人头支付的方式相结合,可能创造出维护健康的激励机制;在把握宏观改革方向的基础上,科学的绩效管理方法、信息化技术和初级保健能够为医院发展和医疗卫生服务体系的快速转型发挥巨大的推动作用一     

中美医学院校经费来源对比分析

经费不足是制约我国医学教育进一步发展的主要因素。该通过对美国公立医学院和我国医学院校经费来源现状的对比,分析了我国高等医学教育筹资中存在的主要问题,并联系我国教育体制改革、卫生体制改革等方面的实际,提出了相应的对策建议。     

Ambiguities of chronic illness management and challenges to the medical error paradigm

In recent decades, an interdisciplinary quality assurance (QA) movement has emerged in health care studies, which has included increased attention to medical errors. Implicit in this QA effort is a conflict between (1) external agents encouraging the medical profession to adopt strategies for reducing errors and (2) sociological characteristics of medical practice that systematically inhibit the uptake of these strategies. Using interviews with providers and observations in two diabetes clinics in a large Midwestern city in the USA, we examine how providers understand error in their work, as well as how they think about failures in care and efforts to standardize and impose guidelines in care. We find that the prototypical vocabularies of medical error and QA, which have been largely oriented to acute illness care, are systematically mismatched to ambiguities introduced by chronic illness. These ambiguities create problems for the definition of medical errors, the collection of relevant information, the determination of long-term treatment goals, and the application of standardization efforts. Considered together, these mismatches imply diminishing returns for health policy efforts focused on reducing medical error as part of a larger QA agenda.     

建设有职业教育特色的医用电子仪器专业

根据医学装备的职业教育需求,从自主研发实验实训设备入手,改变传统的教学方法,突出实践技能的培养,产、学、研结合,建设具有职业教育特色的医用电子仪器专业。     

Review of 128 quality of care mechanisms: A framework and mapping for health system stewards

Health system stewards have the critical task to identify quality of care deficiencies and resolve underlying system limitations. Despite a growing evidence-base on the effectiveness of certain mechanisms for improving quality of care, frameworks to facilitate the oversight function of stewards and the use of mechanisms to improve outcomes remain underdeveloped. This review set out to catalogue a wide range of quality of care mechanisms and evidence on their effectiveness, and to map these in a framework along two dimensions: (i) governance subfunctions; and (ii) targets of quality of care mechanisms. To identify quality of care mechanisms, a series of searches were run in Health Systems Evidence and PubMed. Additional grey literature was reviewed. A total of 128 quality of care mechanisms were identified. For each mechanism, searches were carried out for systematic reviews on their effectiveness. These findings were mapped in the framework defined. The mapping illustrates the range and evidence for mechanisms varies and is more developed for some target areas such as the health workforce. Across the governance sub-functions, more mechanisms and with evidence of effectiveness are found for setting priorities and standards and organizing and monitoring for action. This framework can support system stewards to map the quality of care mechanisms used in their systems and to uncover opportunities for optimization backed by systems thinking.     

Improving the practice of pediatric patient education: A synthesis and selective review

Patient education within the pediatric-care setting can be defined as any combination of planned learning experiences designed to facilitate adaptations of behavior conducive to health. It is directed both toward patients and toward significant adult caretakers in the child's environment. Additionally, health promotion and health education outside of the patient-care setting are required to promote child health. These efforts include legislation directed toward environmental hazards as well as community- and school-based health education programs. Although educating children and their parents is a routine part of pediatric health care, patient education efforts often reflect poorly applied principles of learning. Social learning theory provides useful constructs that can serve as a basis for developing, implementing, and evaluating pediatric patient education. These constructs focus attention on environmental influences on the learner, the role of modeled behavior for health outcomes in children, and the key concepts of perceived self-efficacy and family and social support.     

新生儿家长儿童保健知识认知现状及健康教育需求调查

目的 了解新生儿家长对儿童保健知识的知晓情况、健康教育的需求和乐意接受的健康教育形式,有针对性地为父母进行科学育儿技能的培训提供依据.方法 采用自编问卷对99名新生儿家长进行调查.结果 新生儿家长的儿童保健知识知晓率较低(47.2%),对健康教育的需求依次为小儿生长发育是否正常(70.7%),小儿常见疾病的预防(69.7%),儿童营养与喂养(60.6%),早期教育的方法(60.6%),小儿家庭护理知识(50.5%),婴幼儿智能发育规律(48.5%),小儿意外伤害的预防(36.4%).结论 应广泛开展形式多样的健康教育,提高家长的儿童保健知识水平,引导家长认识到婴幼儿早期教育、小儿意外伤害预防的重要性.