公立医院纵向整合对医疗质量的影响研究

通过设定胃溃疡患者主诊断治疗效果和住院日的影响函数,利用样本整合前1年与整合后4年的相关数据,通过Logistic回归和多元线性回归分析了医院纵向整合对医疗质量的影0向。结果发现,医院纵向整合对整合医院的治疗效果从整合后的第4年开始有显著性影响,对住院日没有显著性影响。     

医疗集团资源纵向整合的实践和探讨

随着我国医疗卫生体制改革的不断深入,出现了不同类型的医疗集团及运作模式。以二、三级综合性医院所有权与经营权分离的托管模式所组建的医疗集团,发挥了资源纵向整合的优势,这一运作机制对全面提升二级综合性医院的管理,提高医疗技术水平,扩大医疗市场发挥了积极、有效的作用。     

Improvements in Health Status after Massachusetts Health Care Reform

Context

Massachusetts enacted health care reform in 2006 to expand insurance coverage and improve access to health care. The objective of our study was to compare trends in health status and the use of ambulatory health services before and after the implementation of health reform in Massachusetts relative to that in other New England states.

Methods

We used a quasi-experimental design with data from the Behavioral Risk Factor Surveillance System from 2001 to 2011 to compare trends associated with health reform in Massachusetts relative to that in other New England states. We compared self-reported health and the use of preventive services using multivariate logistic regression with difference-in-differences analysis to account for temporal trends. We estimated predicted probabilities and changes in these probabilities to gauge the differential effects between Massachusetts and other New England states. Finally, we conducted subgroup analysis to assess the differential changes by income and race/ethnicity.

Findings

The sample included 345,211 adults aged eighteen to sixty-four. In comparing the periods before and after health care reform relative to those in other New England states, we found that Massachusetts residents reported greater improvements in general health (1.7%), physical health (1.3%), and mental health (1.5%). Massachusetts residents also reported significant relative increases in rates of Pap screening (2.3%), colonoscopy (5.5%), and cholesterol testing (1.4%). Adults in Massachusetts households that earned up to 300% of the federal poverty level gained more in health status than did those above that level, with differential changes ranging from 0.2% to 1.3%. Relative gains in health status were comparable among white, black, and Hispanic residents in Massachusetts.

Conclusions

Health care reform in Massachusetts was associated with improved health status and the greater use of some preventive services relative to those in other New England states, particularly among low-income households. These findings may stem from expanded insurance coverage as well as innovations in health care delivery that accelerated after health reform.     

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.     

Quality of Health Care: The Views of Homeless Youth

Objective. To develop homeless-youth-identified process and outcome measures of quality of health care.
Data Sources/Study Setting. Primary data collection with homeless youth from both street and clinic settings in Seattle, Washington, for calendar year 2002.
Study Design. The research was a focused ethnography, using key informant and in-depth individual interviews as well as focus groups with a purposeful sample of 47 homeless youth aged 12–23 years.
Data Collection/Extraction Methods. All interviews and focus groups were tape-recorded, transcribed, and preliminarily coded, with final coding cross-checked and verified with a second researcher.
Principal Findings. Homeless youth most often stated that cultural and interpersonal aspects of quality of care were important to them. Physical aspects of quality of care reported by the youth were health care sites separate from those for homeless adults, andsites that offered a choice of allopathic and complementary medicine. Outcomes of health care included survival of homelessness, functional and disease-state improvement, and having increased trust and connections with adults and with the wider community.
Conclusions. Homeless youth identified components of quality of care as well as how quality of care should be measured. Their perspectives will be included in a larger follow-up study to develop quality of care indicators for homeless youth.     

An Empty Toolbox? Changes in Health Plans' Approaches for Managing Costs and Care

Objective. To examine how health plans have changed their approaches for managing costs and utilization in the wake of the recent backlash against managed care.
Data Sources/Study Setting. Semistructured interviews with health plan executives, employers, providers, and other health care decision makers in 12 metropolitan areas that were randomly selected to be nationally representative of communities with more than 200,000 residents. Longitudinal data were collected as part of the Community Tracking Study during three rounds of site visits in 1996–1997, 1998–1999, and 2000–2001.
Study Design. Interviews probed about changes in the design and operation of health insurance products—including provider contracting and network development, benefit packages, and utilization management processes—and about the rationale and perceived impact of these changes.
Data Collection/Extraction Methods. Data from more than 850 interviews were coded, extracted, and analyzed using computerized text analysis software.
Principal Findings. Health plans have begun to scale back or abandon their use of selected managed care tools in most communities, with selective contracting and risk contracting practices fading most rapidly and completely. In turn, plans increasingly have sought cost savings by shifting costs to consumers. Some plans have begun to experiment with new provider networks, payment systems, and referral practices designed to lower costs and improve service delivery.
Conclusions. These changes promise to lighten administrative and financial burdens for physicians and hospitals, but they also threaten to increase consumers' financial burdens.     

医护人员的压力及压力管理

不断增大的压力是现代社会的一个特点．由于医学的高风险性、不确定性和信息不对称性，医护人员面临着更大的压力．文章探讨了压力的定义、医护人员的压力状况和压力源，以及压力的表现和负性作用，最后集中提出了几点压力管理的策略，以此来帮助医护人员学会如何应对自己面临的压力，提高个人的健康和工作质量。     

Quality Indicators of Primary Care Provider Engagement in Nursing Home Care

The initiative described here aims to identify quality indicators (QIs) germane to the international practice of primary care providers (PCP) in post-acute and long-term care in order to demonstrate the added value of medical providers in nursing homes (NHs). A 7-member international team identified and adapted existing QIs to the AMDA competencies for medical providers. QI sources included the ACOVE 3 Quality Indicators (2007), NH Quality Indicators (2004), NH Residential Care Quality Indicators (2002), and AGS Choosing Wisely (2014). We recruited a technical expert panel (TEP) consisting of 11 panelists from the US, Canada, and the European Union, selected for their knowledge and leadership in post-acute and long-term care. The TEP, using a RAND Modified Delphi approach, provided pre-meeting ratings, discussed items in-person for clarification, and re-rated items following discussion. When panelists rated more than 1 option for a particular QI as valid and feasible, the most stringent option was selected for inclusion in the final candidate set of QIs. Panelists confidentially rated an initial 103 items on validity and feasibility of implementation. During the meeting, panelists added 18 QIs and modified 18. In post-meeting analysis, we eliminated 7 QIs rated not valid and 11 QIs for which a more stringent QI was rated valid and feasible. This resulted in a final set of 95 QIs rated valid and feasible and 8 rated valid but not feasible. This set of QIs for PCPs in the NH identified practices in which provider engagement adds value through expertise in geriatric syndromes, employing evidence-based practice, advocating for residents, delivering person-centered care, facilitating advance care planning, and communicating effectively to coordinate care. Next steps include pilot testing and evaluating the association between adherence to QIs, PCP staffing models, and better outcomes.     

The Meaning of Quality in Health Care: A Conceptual Analysis

During the past three decades, there has been an ongoing debate on the quality of health care. Defining quality is an important part of it. This paper offers a review of definitions and a conceptual analysis in order to understand and explain the differences between them. The analysis results in a semantic rule, expressing the meaning of quality as an optimal balance between possibilities realised and a framework of norms and values. This rule is postulated as a formal criterion of meaning, e.g. when (correctly) applied people understand each other. The rule suits the abstract nature of the term "quality." Quality doesn't exist as such. It is constructed in an interaction between people. This interaction is guided by rules in order to transfer information, e.g. communicate on quality. The rule improves our ability to discuss the debate on quality and to develop a theory grounding actions such as quality assurance or quality improvement.     

The Relation of Quality Indicators to Provider Knowledge of Child Development in Family Child Care Homes

There are continuing concerns about the quality of care offered in family child care homes. One concern is the relationship between regulated structural indicators of quality (training, education, and experience) and process quality indicators (provider engagement with children). This study examined (1) the relationship between structural and process indicators and (2) provider knowledge in predicting process quality. Results suggested that structural indicators of licensure and training were significantly related to process quality. In addition, provider knowledge of child development and health care practices were significant predictors of process quality above structural indicators. Recommendations for trainers and regulatory agencies are discussed.     

军队保健医师能力素质建设

干部保健工作不仅是医疗服务,也是政治任务,事关党、国家和军队的安定和稳定,其发展过程经历萌芽、发展、曲折中前进、壮大等几个过程,逐步形成一套科学的体系.保健医师是干部保健工作的主体,军队保健医师因保健对象的特殊性与临床医师相比有很大区别.但绝大多数由临床医师转来,与实际保健需求有一定差距.重视和开展军队保健医师的能力素质建设和模块化层级式培训,以符合新时期强军保健任务的需要,有利于保健医师能力的提高和技术的进步,为保健政策的制定提供科学的数据支撑.     

Leadership and Quality of Working Life in Home Health Care

Home health care has undergone startling changes in the past decade and, in the process, become a strategically important ingredient of health care delivery. However, the question remains whether home health care organizations can deliver the benefits anticipated for integrated care delivery systems. The answer to this question depends to a great extent on whether home health care organizations build vibrant, visionary leadership capable of transforming organizations and motivating staff to deliver high quality and low cost services. This paper examines a case study of transformational leadership as it relates to the quality of working life for nurses, homemakers, and staff. The findings indicate that leader behavior is strongly associated with homemakers', and to a lesser extent staff members', job satisfaction, job involvement, and propensity to remain with the organization. These job attitudes have been shown to be related to higher job performance. The implications for leadership in home health agencies are discussed.     

Child Care Provider Perspectives on the Role of Education and Training for Quality Caregiving

This study describes child care providers' reports of the types of training necessary for quality caregiving and their beliefs about the level of training and education required for child care workers. 70 providers (25 center directors, 19 center providers, and 26 home providers) participated in 8 focus groups that were conducted as part of a larger statewide assessment of child care provider training needs. Providers most frequently listed 1) Health, Safety, and Nutrition, 2) Child Development; and 3) Developmentally Appropriate Practices and Learning Environments as important topics for child care training. When asked to identify a level of training and education for child care workers, providers endorsed 3 different types of preparation: education, life experience (e.g., parenting), and personal attributes (e.g., patience). Center providers were more likely than home providers to identify education and providers with child-care relevant education were more likely than providers with no post-high school preparation to endorse education. Results are discussed in terms of providers' perceptions of professional worth and the design of educational and professional development initiatives.     

Professional and Personal Quality of Care in Health Care Delivery

No abstract available for this article.