Biomedicine, holism and general medical practice: responses to the 2004 General Practitioner contract

In 2004 a new contract was introduced for General Practitioners in the UK, which introduced a significant element of 'pay-for-performance', including both clinical and organisational targets. The introduction of this contract has caused interest across the world, particularly amongst those responsible for commissioning primary care services. It can be argued that the clinical targets in the contract (known as the Quality and Outcomes Framework, QOF) represent a move towards a more biomedical model of health and illness, which is contrary to the ideal of providing holistic (or biopsychosocial) care that has been traditionally espoused by GPs. This paper reports results from two linked studies (in England and Scotland) investigating the early stages of the new contract. We describe the way in which four practices with different organisational approaches and espoused identities have all changed their practice structures, consultations and clinical care in response to QOF in ways which will result in patients receiving a more biomedical type of care. In spite of these observed changes, respondents continued to maintain discursive claims to holism. We discuss how this disconnection between rhetoric and reality can be maintained, and consider its implications for the future development of GPs' claims to a professional identity.     

论我国推行全科医生制度的经济意义

我国进入21世纪以后,人口的老龄化进程加快,医疗供需脱节的现状要求全科医生尽快进入医疗领域。与发达国家不同,我国的全科医生尚处于初级阶段,主要表现为数量少、素质低。国家通过政策法规推行全科医生制度,目的在于它具有积极的经济意义:①促进国家对医疗卫生事业投入的增加;②产生巨大的市场价值;③缓解"看病贵、看病难"的医疗危机。     

The impact of pay-for-performance on professional boundaries in UK general practice: an ethnographic study

The 2004 new General Medical Services (nGMS) contract exemplifies trends across the public services towards increased definition, measurement and regulation of professional work, with general practice income now largely dependent on the quality of care provided across a range of clinical and organisational indicators known collectively as the 'Quality and Outcomes Framework' (QOF). This paper reports an ethnographically based study of the impact of the new contract and the financial incentives contained within it on professional boundaries in UK general practice. The distribution of clinical and administrative work has changed significantly and there has been a new concentration of authority, with QOF decision making and monitoring being led by an internal QOF team of clinical and managerial staff who make the major practice-level decisions about QOF, monitor progress against targets, and intervene to resolve areas or indicators at risk of missing targets. General practitioners and nurses, however, appear to have accommodated these changes by re-creating long established narratives on professional boundaries and clinical hierarchies. This paper is concerned with the impact of these new arrangements on existing clinical hierarchies.     

The Rise and Fall in Out‐of‐Pocket Costs in Australia: An Analysis of the Strengthening Medicare Reforms

After a period of steady decline, out‐of‐pocket (OOP) costs for general practitioner (GP) consultations in Australia began increasing in the mid‐1990s. Following the rising community concerns about the increasing costs, the Australian Government introduced the Strengthening Medicare reforms in 2004 and 2005, which included a targeted incentive for GPs to charge zero OOP costs for consultations provided to children and concession cardholders (older adults and the poor), as well as an increase in the reimbursement for all GP visits. This paper examines the impact of those reforms using longitudinal survey and administrative data from a large national sample of women. The findings suggest that the reforms were effective in reducing OOP costs by an average of $A0.40 per visit. Decreases in OOP costs, however, were not evenly distributed. Those with higher pre‐reform OOP costs had the biggest reductions in OOP costs, as did those with concession cards. However, results also reveal increases in OOP costs for most people without a concession card. The analysis suggests that there has been considerable heterogeneity in GP responses to the reforms, which has led to substantial changes in the fees charged by doctors and, as a result, the OOP costs incurred by different population groups. Copyright © 2016 John Wiley & Sons, Ltd.     

标准化患者用于全科医师考核中的评价分析

目的 评价和分析标准化患者用于全科医师考核中的作用.方法 对2008年至今参加过全科医师考核的19名标准化患者、57名全科医师及24名评委,进行有关标准化患者用于全科医师考核的问卷调查,并统计相关数据.结果 尽管存在个别差异,但是从统计学分析,无论是标准化患者、全科医师还是评委都对标准化患者用于全科医师考核持肯定态度.结论 标准化患者用于全科医师考核是有意义的、合理的、可行的、公正的.     

梅州市农村全科医生转岗培训效果及其影响因素研究

目的 评价全科医生转岗培训效果并分析其影响因素,为改进全科医生转岗培训方案的提供研究证据.方法 问卷调查和定性访谈广东省梅州市乡镇卫生院参加全科医生转岗培训的学员.结果 转岗培训学员培训前和培训后在全科医学理论知识掌握、临床技能和基层实践能力上都有所提高,对于知识和技能的熟悉程度在统计学上具有差异.结论 学员对知识的需求程度、轮转培训医院师资的教学能力等是影响培训效果的主要因素.     

英国家庭医生制度对我国分级诊疗模式的启示

实行家庭医生(GP)制度是英国NHS获得成功的一个重要因素.通过简要分析英国GP制度的特点,获得对我国医改分级诊疗的启示,必须加强顶层设计,制定全国统一的医师准人标准,重视对患者需求的有效梳理和引导,寻求社会诚信,从而提升整个医疗服务体系的效率.     

基层医疗绩效考核改革实施情况

目的 了解上海市新一轮家庭医生绩效考核工作的实施情况,探讨绩效考核对家庭医生激励作用的影响因素.方法 采用分层整群随机抽样调查方法,从上海市65家试点社区卫生服务中心中,按中心城区、城乡接合部、郊区3个层次,抽取10家社区卫生服务中心,以抽中单位的全部在岗家庭医生作为研究对象,共收集270名家庭医生的调查问卷,调查内容包括本单位绩效考核的实施情况、有无起到激励作用等.结果 有94.4％的家庭医生知晓绩效考核改革试点工作,不同地区间有统计学差异(X2=24.425,P＜0.0001);有230人(85.2％)认为本单位绩效考核及薪酬分配方案公开透明,且不同地区间有统计学差异(X2=21.77,P＜0.0001);有198人(73.3％)表示本单位反馈绩效考核结果,不同地区之间有统计学差异(X 2=30.430,P＜0.0001).212例(78.5％)认为通过绩效考核改革能够激励自身更好地投入工作.多因素Logistics回归分析显示,所在地区、绩效考核及薪酬分配方案的形成过程是否公开透明、考核结果是否反馈、绩效工资提升的比例是家庭医生激励作用的影响因素.结论 上海市试点社区卫生服务中心的家庭医生绩效考核实施总体情况良好,家庭医生对绩效考核工作的知晓度高,其中城乡接合部的实施情况好于中心城区,郊区较差.绩效考核方案公开透明、反馈考核结果、绩效工资提升幅度是家庭医生激励作用产生的重要因素.     

2007年山东省部分基层全科医生慢性病防治知识调查

[目的]了解基层全科医生慢性病防治知识知晓情况,为开展基层全科医生慢性病教育培训提供依据。[方法]2007年4月,在山东省6个市对接受培训的基层全科医生于培训后进行问卷调查。[结果]调查基层全科医生1047名,其中大学本科及以上学历者占25.02%;知道高血压的定义和分类的占88.44%,知道肥胖诊断标准的占61.41%,知道世界糖尿病宣传日时间的占58.16%,知道高血压宣传日时间的占56.92%;对重点人群进行过健康教育宣传的占38.30%,对重点人群进行过高血压、糖尿病筛查的占44.13%。[结论]山东省基层全科医生高血压、糖尿病相关防治知识水平不高。     

Doing Better to Do Good: The Impact of Strategic Adaptation on Nursing Home Performance

Objective. To test the hypothesis that a greater commitment to strategic adaptation, as exhibited by more extensive implementation of a subacute/rehabilitation care strategy in nursing homes, will be associated with superior performance.
Data Sources. Online Survey, Certification, and Reporting (OSCAR) data from 1997 to 2004, and the area resource file (ARF).
Study Design. The extent of strategic adaptation was measured by an aggregate weighted implementation score. Nursing home performance was measured by occupancy rate and two measures of payer mix. We conducted multivariate regression analyses using a cross-sectional time series generalized estimating equation (GEE) model to examine the effect of nursing home strategic implementation on each of the three performance measures, controlling for market and organizational characteristics that could influence nursing home performance.
Data Collection/Abstraction Methods. OSCAR data was merged with relevant ARF data.
Principal Findings. The results of our analysis provide strong support for the hypothesis.
Conclusions. From a theoretical perspective, our findings confirm that organizations that adjust strategies and structures to better fit environmental demands achieve superior performance. From a managerial perspective, these results support the importance of proactive strategic leadership in the nursing home industry.     

General practitioners’ perceptions of treatment of chronically ill patients managed in general practice: An interview study

BackgroundPatients with chronic conditions pose a major challenge to the Danish healthcare system. Since 2018, disease management programmes for patients with chronic obstructive pulmonary disease (COPD) and type 2 diabetes (T2D) were introduced in Denmark. Treatment in hospitals should be reserved for those patients who require specialised treatment. Hence, more patients with COPD and T2D fall within the general practitioners’ (GPs) responsibility.ObjectivesThis study explores GPs’ perceptions of their role as physicians responsible for the disease management programmes on COPD and T2D and their perceptions of the quality of care provided to these patient groups.MethodsBetween November 2019 and January 2020, we conducted semi-structured interviews with 14 GPs from the five regions of Denmark. We analysed the interviews using systematic text condensation inspired by Malterud’s thematic analysis.ResultsThe GPs stated that they have been managing the care of COPD and T2D patients for over a decade, and they considered the quality of care to be high. They believed that managing patient treatment pathways in general practice settings contributes to a heightened sense of security for the patient, mainly because of the long-standing and trusting relationship between the patient and GP.ConclusionAccording to the GPs, they continue to play an important role as treatment coordinators to ensure coherence and high quality in treating patients with COPD and type 2 diabetes.     

A Note on the Comparative Statics of Pay‐for‐Performance in Health Care

Pay‐for‐performance (P4P) is a widely implemented quality improvement strategy in health care that has generated much enthusiasm, but only limited empirical evidence to support its effectiveness. Researchers have speculated that flawed program designs or weak financial incentives may be to blame, but the reason for P4P's limited success may be more fundamental. When P4P rewards multiple services, it creates a special case of the well‐known multitasking problem, where incentives to increase some rewarded activities are blunted by countervailing incentives to focus on other rewarded activities: these incentives may cancel each other out with little net effect on quality. This paper analyzes the comparative statics of a P4P model to show that when P4P rewards multiple services in a setting of multitasking and joint production, the change in both rewarded and unrewarded services is generally ambiguous. This result contrasts with the commonly held intuition that P4P should increase rewarded activities. Copyright © 2015 John Wiley & Sons, Ltd.     

GPs and the social amplification of BSE-related risk: An empirical study

Social studies of risk have consistently shown that physicians and health professionals are viewed by the general public as a trustworthy source of information and communication regarding risks. However, few if any empirical investigations have focused on the role physicians, particularly general practitioners (GPs), may play as a ‘social station’ in the processes of amplification or attenuation of risks to health that Kasperson et al described in their framework. The purpose of the present study is to investigate whether French GPs acted as amplifiers or attenuators in the BSE (‘mad cow disease’) crisis. A sample of 602 general practitioners completed a questionnaire aimed at assessing in a variety of ways their cognitive, affective and behavioural responses to BSE. Results show that, (1) GPs expressed moderate concern about BSE-related risks: Mad cow disease only ranked tenth in averaged ratings of 14 current risks to health. (2) However, about 90% of respondents reported having recommended one or several modifications in their patients' food habits. Remarkably, only 44% did the same at home. (3) By far the most common recommendation was to avoid organ meats from cattle, even though specified risk materials (which included some of those cuts) had been withdrawn from the market as early as April 1996. Such results point to potentially complex—perhaps even contradictory—responses to BSE from the GPs, with a clear dichotomy between reported private and professional behaviour. Our data suggest that social agents may act simultaneously as risk amplifiers and risk attenuators depending on the public towards which their communication was directed.     

基于VAR模型的我国综合医院经济效率及其影响因素分析

目的:明确我国综合医院经济效率的影响因素及影响程度,切实促进我国医疗卫生事业高质量发展。方法:建立向量自回归模型(VAR模型)并对2003—2018年我国主要综合医院数据进行分析。结果:我国综合医院医疗效率受医院数量、医务人员数量、政府卫生支出、社会卫生支出等因素影响较为明显。其中政府卫生支出、社会卫生支出对的影响路径基本相同,且影响具有稳定性。结论:科学合理的配备医院与医务人员数量能够积极有效的提升我国综合医院医疗效率。数量配备不足与超过必要限度,均将降低我国综合医院整体效率。我国应通过科学的管理与精湛的医疗技术最大限度地提升我国综合医院医疗效率,提升患者满意度,积极引领我国医疗卫生事业高质量发展。     

综合医院心理咨询门诊儿童咨客分析

目的；了解综合医院心理咨询门诊儿童咨客的特点。方法：总结中山大学附属三院心理咨询门诊近3年儿童咨客的资料。结果：咨客男女比例为1．96：1，咨客人数随着年龄的增长而增加，女童中13－16岁的比例男童大，5－8岁和9－12岁的比例较男童小。广州市内外的咨客比例为1．38：1，不同年龄儿童咨客的居住地构成是有差异的。最常见的病种是精神分裂症，神经症、精神发育迟滞，儿童多动症，单纯咨询和品行障碍，不同年龄，不同性别的儿童咨客的疾病构成是有差异的。结论：综合医院心理咨询门诊与儿童心理咨询门诊的儿童咨客是有差异的。     

Optimizing the care of patients with depression in primary care: the views of general practitioners

Depression is a very common mental illness within the general population and in-patients consulting in general practice. General practitioners are well placed to provide care for patients with mental health problems, as these disorders are often connected with family and social problems, and GPs can provide their patients with long-term follow-up and support. While there are theoretical reasons for the important role of the family doctor, there is limited evidence about how general practitioners view their roles and their capacity to cope with the mental health needs of their patients. This paper explores the experience of 15 general practitioners from Scotland, who were interviewed during the spring of 1998, about how they approached the care of patients with depression in relation to their skills, knowledge and attitudes. The following four key categories of interest are presented which underpin the emergent themes of the study: (1) organizational issues; (2) referral and the use of other professionals; (3) treatment and management issues; (4) stigma. These themes reveal some interesting issues in relation to GPs' recognition and management of depression and it is also clear that the perception of collaboration within primary care and between primary and secondary care is an integral part of the process. The implications of what has been learned from this study may include the development of educational opportunities for GP trainees and established principals, in addition to brief multidisciplinary training opportunities and shared learning events between primary and secondary care.     

The Relationship between Health Behavior and General Health Status: Based on 2011 Korea National Health and Nutrition Examination Survey

Objectives

The aim of the present study is to investigate the relationship between health behavior and general health status.

Methods

We used data from the 2011 Korea National Health and Nutrition Examination Survey. Mental health was measured by stress recognition and depression. Dietary habit was measured by mixed grain diet. Life pattern was measured by sleeping time and working pattern. Physical activity was measured by walking and exercise. We defined general health status as Euro Quality of Life-5 Dimension (EQ-5D_index), Euro Quality of Life Visual Analogue Scale (EQ-5D_vas), number of people experienced lying in a sickbed for the last one month, number of days lying in a sickbed for the last one month, and activity limitations.

Results

Mental health, dietary habit, life pattern, and physical activity have seven factors. Most of the factors have a significant correlation with EQ-5D_index, EQ-5D_vas, number of people experienced lying in a sickbed for the last one month, number of days lying in a sickbed for the last one month, and activity limitations.

Conclusion

Health behavior and general health status have a positive correlation.     

大型综合性医院临床医师“三基”现状分析与思考

通过对某三级甲等综合性医院当前临床医师“三基”现状及存在问题的分析，提出相应的方法、措施等意见和建议，供今后进一步改进与完善“三基”工作提供参考。