乡镇卫生院绩效管理研究述评

在阐述乡镇卫生院绩效管理的战略地位的基础上,对我国乡镇卫生院绩效管理的研究进展和现存问题进行了剖析,对国外同级别机构,即初级卫生保健机构绩效管理的现状进行了案例介绍和经验总结,最后提出了下一阶段我国乡镇卫生院绩效管理实践的重点内容与方法,包括以持续改进为管理目标,落实并完善绩效沟通,以及创新绩效管理实施效果评价机制,由此为形成乡镇卫生院长效发展机制和巩固基层医改成果提供了决策依据和参考.     

Psychosocial Problems among Patients in Neighborhood Health Centers: Perspectives from Health Care Providers

Little is known about how health care professionals perceive and understand the psychosocial problems of individuals receiving services in neighborhood health centers (NHCs). We conducted interviews with health care professionals in NHCs in New York City. The respondents identified seven problems, including a lack of financial resources, unsafe housing, and emotional distress/depression as affecting large portions of their patient populations. Respondents reported that they are presently meeting many of the psychosocial needs of their clients, but they were pessimistic about their ability to continue to do so due to a lack of funding streams to support their provision of comprehensive health care that includes psychosocial services. The findings suggest that while NHCs may be holding their own in providing quality services to their clients, this will be harder to sustain in the future if the numbers of the uninsured served continues to increase, and the revenues generated continue to decrease.Victoria M. Rizzo is Research Assistant Professor and Executive Director of the Elder Network of the Capital Region at the School of Social Welfare, University at Albany, State University of New York, Albany, New York. Terry Mizrahi is Professor, Hunter College of Social Work, New York, New York. Kristen Kirkland is a Doctoral Student, Center for Excellence in Aging Services, School of Social Welfare, University at Albany, State University of New York.Requests for reprints should be addressed to Victoria M. Rizzo, PhD, Elder Network of the Capital Region, School of Social Welfare, University at Albany, State University of New York, 135 Western Avenue, Albany, NY 12222, USA; e-mail: vmrizzo@albany.edu.     

Private Care and Public Health: Do Vaccination and Prenatal Care Rates Differ between Users of Private versus Public Sector Care in India?

Objective. To determine whether patients who use private sector providers for curative services have lower vaccination rates and are less likely to receive prenatal care.
Data Sources/Study Setting. This study uses data from the 52d round of the National Sample Survey, a nationally representative socioeconomic and health survey of 120,942 rural and urban Indian households conducted in 1995–1996.
Study Design. Using logistic regression, we estimate the relationship between receipt of preventive care at any time (vaccinations for children, prenatal care for pregnant women) and use of public or private care for outpatient curative services, controlling for demographics, household socioeconomic status, and state of residence.
Data Collection/Extraction Methods. We analyzed samples of children ages 0 to 4 and pregnant women who used medical care within a 15-day window prior to the survey.
Principal Findings. With the exception of measles vaccination, predicted probabilities of the receipt of vaccinations and prenatal care do not differ based on the type of provider at which children and women sought curative care. Children and pregnant women in households who use private care are almost twice as likely to receive preventive care from private sources, but the majority still obtains preventive care from public providers.
Conclusions. We do not find support for the hypothesis that children and pregnant women who use private care are less likely to receive public health services. Results are consistent with the notion that Indian households are able to successfully navigate the coexisting public and private systems, and obtain services selectively from each. However, because the study employed an observational, cross-sectional study design, findings should be interpreted cautiously.     

Waste in the U.S. Health Care System: A Conceptual Framework

Context: Health care costs in the United States are much higher than those in industrial countries with similar or better health system performance. Wasteful spending has many undesirable consequences that could be alleviated through waste reduction. This article proposes a conceptual framework to guide researchers and policymakers in evaluating waste, implementing waste‐reduction strategies, and reducing the burden of unnecessary health care spending. Methods: This article divides health care waste into administrative, operational, and clinical waste and provides an overview of each. It explains how researchers have used both high‐level and sector‐ or procedure‐specific comparisons to quantify such waste, and it discusses examples and challenges in both waste measurement and waste reduction. Findings: Waste is caused by factors such as health insurance and medical uncertainties that encourage the production of inefficient and low‐value services. Various efforts to reduce such waste have encountered challenges, such as the high costs of initial investment, unintended administrative complexities, and trade‐offs among patients', payers', and providers' interests. While categorizing waste may help identify and measure general types and sources of waste, successful reduction strategies must integrate the administrative, operational, and clinical components of care, and proceed by identifying goals, changing systemic incentives, and making specific process improvements. Conclusions: Classifying, identifying, and measuring waste elucidate its causes, clarify systemic goals, and specify potential health care reforms that—by improving the market for health insurance and health care—will generate incentives for better efficiency and thus ultimately decrease waste in the U.S. health care system.     

The impact of Community Health Centers on inappropriate use of emergency services

Community Health Centers offer coordinated and comprehensive responses to primary care needs. Our study aims at assessing whether the introduction of such organizational model improved health outcomes measured by inappropriate emergency visits among diabetics in the Emilia-Romagna region of Italy. Using difference-in-differences methods within a staggered treatment setting, we estimate the effect of Community Health Center participation on inappropriate hospital emergency visits between year 2010 and year 2016. We distinguish between emergency department admissions for varying time spans, occurring at daytime during working days, at night-time, as well as during weekends. We show that, the causal effect of the adoption of the community care model leads to a reduction in the probability of inappropriate admissions by an amount ranging between 1.6 and 1.7% points during working days at daytime, with large facilities responsible for most gains by experiencing a decrease ranging between 4 and 3% points. Conversely, we detect no difference at night-time and during weekends. Our results point out that the coordinated care model increases appropriateness among vulnerable patients, and that extending opening hours and the range of services can further enhance such benefits.     

积极开展农村社区卫生服务不断提高初级卫生保健水平

实施“农民健康工程”,紧紧围绕为人民健康和经济建设、服务这一中心,以初级卫生保健为目标,以卫生机构改革、管理一体化为基础,以合作医疗为保障,大力开展农村社区卫生服务,有效缓解农民群众看病贵、看病难的问题。     

开封市社区人群健康素质分析

目的：了解开封市社区居民健康水平,为社区卫生保健、社区健康教育措施的制定提供依据。方法：按行政分区抽取户口在开封市的常驻7-14岁儿童1832名,18岁以上社区居民800名,采用自行设计问卷调查表对这部分儿童及居民进行调查。结果：⑴按社区人口诊断标准,开封市人口属“老年人口型”。⑵儿童6种疫苗接种率与全国及城市级别水平相比较高,但儿童常见疾病患病率较高。⑶社区人群的防治疾病、合理营养知识匮乏。讨论：本次调研采用社区健康分析方法,从人口特征、人群营养与发育、常见疾病三个方面对开封市社区健康状况进行评价：开封市社区少年儿童负担系数、老年负担系数、老化指数都较高;儿童存在着不良个人卫生习惯,社区人群的自我保健意识很差。针对社区的这种健康状况,应开展以营养知识和常见病防治为内容的社区健康教育及卫生保健工作。     

The Cost-Effectiveness of Improving Diabetes Care in U.S. Federally Qualified Community Health Centers

Objective. To estimate the incremental cost-effectiveness of improving diabetes care with the Health Disparities Collaborative (HDC), a national collaborative quality improvement (QI) program conducted in community health centers (HCs).
Data Sources/Study Setting. Data regarding the impact of the Diabetes HDC program came from a serial cross-sectional follow-up study (1998, 2000, 2002) of the program in 17 Midwestern HCs. Data inputs for the simulation model of diabetes came from the latest clinical trials and epidemiological studies.
Study Design. We conducted a societal cost-effectiveness analysis, incorporating data from QI program evaluation into a Monte Carlo simulation model of diabetes.
Data Collection/Extraction Methods. Data on diabetes care processes and risk factor levels were extracted from medical charts of randomly selected patients.
Principal Findings. From 1998 to 2002, multiple processes of care (e.g., glycosylated hemoglobin testing [HbA_1C] [71→92 percent] and ACE inhibitor prescribing [33→55 percent]) and risk factor levels (e.g., 1998 mean HbA_1C 8.53 percent, mean difference 0.45 percent [95 percent confidence intervals −0.72, −0.17]) improved significantly. With these improvements, the HDC was estimated to reduce the lifetime incidence of blindness (17→15 percent), end-stage renal disease (18→15 percent), and coronary artery disease (28→24 percent). The average improvement in quality-adjusted life year (QALY) was 0.35 and the incremental cost-effectiveness ratio was $33,386/QALY.
Conclusions. During the first 4 years of the HDC, multiple improvements in diabetes care were observed. If these improvements are maintained or enhanced over the lifetime of patients, the HDC program will be cost-effective for society based on traditionally accepted thresholds.     

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.     

Index System of Health Services Quality Evaluation on Township Health Centers

THERE IS ABOUT 80% of total population in ruralChina. Rural health care is an important content ofbuilding socialism new villages, and is a big thing tosafeguard peasants’ health and protect agricultureproductivity, invigorate rural economy and maintainsocial stability. So, rural health acre is a pivot ofChina’s health development. In 1997, the policy “tostrengthen rural health organization constructionand to perfect three-level health services systemincluding the county, the town and the village” wasdefini...     

芬兰社区卫生服务模式的特点与思考

芬兰的初级卫生保健工作成效显著,其社区卫生服务模式在组织、人员、管理、服务内容、服务方式和运行保障等方面具有显著的特点,对我国社区卫生服务工作有积极的借鉴意义.结合目前卫生改革的重点和难点,对如何引导人才下沉社区、建立社区首诊、预约诊疗和实行按人头预付费等方面进行了深入的分析和思考.     

美军初级医疗保健模式改革

本文分析美军开展"以患者为中心的医疗之家"初级医疗保健模式改革的动因、进展,阐述这种新模式的内涵、核心原则和优点,并提出对我军初级医疗保健模式建设的启示。     

Health Status and Health Care Experiences among Homeless Patients in Federally Supported Health Centers: Findings from the 2009 Patient Survey

Objective

To examine health status and health care experiences of homeless patients in health centers and to compare them with their nonhomeless counterparts.

Data Sources/Study Setting

Nationally representative data from the 2009 Health Center Patient Survey.

Study Design

Cross-sectional analyses were limited to adults (n = 2,683). We compared sociodemographic characteristics, health conditions, access to health care, and utilization of services among homeless and nonhomeless patients. We also examined the independent effect of homelessness on health care access and utilization, as well as factors that influenced homeless patients'' health care experiences.

Data Collection

Computer-assisted personal interviews were conducted with health center patients.

Principal Findings

Homeless patients had worse health status—lifetime burden of chronic conditions, mental health problems, and substance use problems—compared with housed respondents. In adjusted analyses, homeless patients had twice the odds as housed patients of having unmet medical care needs in the past year (OR = 1.98, 95 percent CI: 1.24–3.16) and twice the odds of having an ED visit in the past year (OR = 2.00, 95 percent CI: 1.37–2.92).

Conclusions

There is an ongoing need to focus on the health issues that disproportionately affect homeless populations. Among health center patients, homelessness is an independent risk factor for unmet medical needs and ED use.     

发展社区卫生服务是实现医改目标的基础

过去30年,我国医疗卫生事业发展出现了一系列的矛盾和问题,如何实现卫生事业的健康发展,更有效地保护全体人群的健康权益,成为我国卫生事业改革的重要目标。从分析我国卫生改革不成功的原因入手,以及分析实现我国新医改"到2020年覆盖城乡居民的基本医疗卫生制度基本建立"目标的关键因素,探讨发展社区卫生服务与实现人人享有基本卫生保健之间的关系,通过分析,认为大力发展社区卫生服务是实现我国新医改目标的重要基础。     

基层基本疾病预防控制项目绩效考核指标研究

背景公共财政制度要求对基层基本疾病预防控制工作实行绩效考核,绩效考核指标则是实行绩效考核的基本前提。方法文献归纳、焦点小组讨论和机构问卷调查。结果针对125个基层基本疾病预防控制项目提出了241个绩效考核指标,经19个样本机构论证,总体认同率为95.2%。结论课题组建立了基层基本疾病预防控制项目绩效考核的指标库,在各地实际操作时需要结合当地实情和工作导向进行取舍和调整。     

Overuse and underuse of diagnostic upper gastrointestinal endoscopy in various clinical settings.

OBJECTIVES: To describe and compare both overuse and underuse of diagnostic upper gastrointestinal endoscopy in different settings. DESIGN: Merging of data from three prospective observational studies. The appropriateness and necessity of indications for gastroscopy were evaluated using explicit criteria developed by a standardized expert panel method (RAND-UCLA). Inappropriate endoscopies represent overuse. Necessary indications not referred for the procedure constitute underuse. SETTING: Three primary care outpatient clinics, 20 general practices, three gastroenterology practices, two district and one university hospitals. SUBJECTS: A third of the collective were consecutive ambulatory patients with upper abdominal complaints, whereas the other two thirds were ambulatory and hospitalized patients referred for the procedure. MAIN OUTCOME MEASURES: Proportions of overuse and underuse in the different settings. RESULTS: A total of 2885 patients were included (mean age, 49 years, 52% male, 2442 outpatients), 1858 patients underwent > or = 1 endoscopy. Among 2086 endoscopies, 805 (39%) were inappropriate, most of which were performed for dyspepsia (83%). Overuse was higher in young, foreign, female patients and lower in inpatient settings, the latter reflecting a different distribution of presenting symptoms. Among 1646 patient visits in primary care, overuse represented 148 endoscopies (9%). Underuse was identified in 104 of the same patient visits (6%) and was higher as patient age increased; there were no significant differences between men and women. CONCLUSIONS: Rates of overuse and underuse depend mainly on case presentation and patient characteristics. Both over- and underuse should be addressed to maintain and improve quality of care.