我院门诊职能转变后绩效分析

目的改变传统门诊就医模式,更加便捷、高效、人性化服务于门诊患者。方法采取明确职责、以人为本、优化就医环境、简化就医流程、规范医疗服务、开设便捷门诊、加强信息化管理、设立专病会诊中心、加强医护人员专业知识及技能培训等多种措施实现门诊职能全方位转变。结果各项整改措施落实到位后,有效调动了各级人员的积极性,门诊就医人数、患者对医疗服务满意度及经济收入等各项指标较前明显增加。结论切实实现门诊职能转变,满足患者各种形式的就医需求,实现医院经济效益和社会效益双丰收。     

Patient-centered cancer treatment planning: improving the quality of oncology care. Summary of an Institute of Medicine workshop

The Institute of Medicine's National Cancer Policy Forum recently convened a workshop on patient-centered cancer treatment planning, with the aim of raising awareness about this important but often overlooked aspect of cancer treatment. A primary goal of patient-centered treatment planning is to engage patients and their families in meaningful, thorough interactions with their health care providers to develop an accurate, well-conceived treatment plan, using all available medical information appropriately while also considering the medical, social, and cultural needs and desires of the patient and family. A cancer treatment plan can be shared among the patient, family, and care team in order to facilitate care coordination and provide a roadmap to help patients navigate the path of cancer treatment. There are numerous obstacles to achieving patient-centered cancer treatment planning in practice. Some of these challenges stem from the patient and include patients' lack of assertiveness, health literacy, and numeracy, and their emotional state and concurrent illnesses. Others are a result of physician limitations, such as a lack of time to explain complex information and a lack of tools to facilitate treatment planning, as well as insensitivity to patients' informational, cultural, and emotional needs. Potential solutions to address these obstacles include better training of health care providers and patients in optimal communication and shared decision making, and greater use of support services and tools such as patient navigation and electronic health records. Other options include greater use of quality metrics and reimbursement for the time it takes to develop, discuss, and document a treatment plan.     

Patient navigator programs, cancer disparities, and the patient protection and affordable care act

Patients in vulnerable population groups suffer disproportionately from cancer. The elimination of cancer disparities is critically important for lessening the burden of cancer. Patient navigator programs have been shown to improve clinical outcomes. Among its provisions relevant to disparities in cancer care, The Patient Protection and Affordability Care Act authorizes continued funding of patient navigator programs. However, given the current economic and political environment, this funding is in jeopardy. This article describes patient navigator programs and summarizes the elements of the health care law that are relevant to these programs. It is vital that the entire oncology community remain committed to leading efforts toward the improvement of cancer care among our most vulnerable patients.     

Fixed Orthodontic Appliance Therapy and Its Impact on Oral Health-Related Quality of Life in Chinese Patients

Objective:To determine changes in oral health-related quality of life (OHRQoL) during fixed orthodontic appliance therapy in Chinese patients.Materials and Methods:Two-hundred fifty Chinese orthodontic patients completed six distinct intervals of the 14-item Oral Health Impact Profile (OHIP-14, Chinese version): before treatment (T0); after the placement of the fixed appliance at 1 week (T1), 1 month (T2), 3 months (T3), and 6 months (T4); and posttreatment (T5).Results:The overall response rate was 88.8% (222 of 250). Significant differences of overall OHIP-14 scores could be found between any two time points (P < .001), except for between T0 and T2 (P > .05) and between T3 and T4 (P > .05). Overall scores at T1 were significantly higher than the scores at the other intervals (P < .001), with a significant change in the scores on physical pain (P < .001), psychological discomfort (P < .001), and physical disability (P < .001). Scores at T5 were lowest among the six time points (P < .001).Conclusions:Fixed orthodontic appliance therapy did affect Chinese patients'' OHRQoL. Patients were considerably compromised in terms of their overall OHRQoL until approximately 1 month after insertion. The severity of the compromised condition in terms of overall OHRQoL was greatest at 1 week with the reported impact on physical pain, psychological discomfort, and physical disability. Patients'' OHRQoL was better after they completed the orthodontic treatment than before or during treatment.     

Notification of Abnormal Lab Test Results in an Electronic Medical Record: Do Any Safety Concerns Remain?

Background

Follow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examined whether automated notifications of abnormal laboratory results (alerts) in an integrated electronic medical record resulted in timely follow-up actions.

Methods

We studied 4 alerts: hemoglobin A1c ≥15%, positive hepatitis C antibody, prostate-specific antigen ≥15 ng/mL, and thyroid-stimulating hormone ≥15 mIU/L. An alert tracking system determined whether the alert was acknowledged (ie, provider clicked on and opened the message) within 2 weeks of transmission; acknowledged alerts were considered read. Within 30 days of result transmission, record review and provider contact determined follow-up actions (eg, patient contact, treatment). Multivariable logistic regression models analyzed predictors for lack of timely follow-up.

Results

Between May and December 2008, 78,158 tests (hemoglobin A1c, hepatitis C antibody, thyroid-stimulating hormone, and prostate-specific antigen) were performed, of which 1163 (1.48%) were transmitted as alerts; 10.2% of these (119/1163) were unacknowledged. Timely follow-up was lacking in 79 (6.8%), and was statistically not different for acknowledged and unacknowledged alerts (6.4% vs 10.1%; P =.13). Of 1163 alerts, 202 (17.4%) arose from unnecessarily ordered (redundant) tests. Alerts for a new versus known diagnosis were more likely to lack timely follow-up (odds ratio 7.35; 95% confidence interval, 4.16-12.97), whereas alerts related to redundant tests were less likely to lack timely follow-up (odds ratio 0.24; 95% confidence interval, 0.07-0.84).

Conclusions

Safety concerns related to timely patient follow-up remain despite automated notification of non-life-threatening abnormal laboratory results in the outpatient setting.     

芬太尼不同配伍方法用于骨科术后静脉镇痛的研究

目的观察芬太尼复合应用及单独用于术后病人自控静脉镇痛(PCIA)的效果及不良反应。方法选择60例ASAⅠ或Ⅱ级行上肢骨科切开复位内固定术患者,随机均分为四组:A组,芬太尼0.02mg/kg;B组,芬太尼0.015mg/kg;C组,芬太尼0.015mg/kg加氯氨酮2.0mg/kg;D组,芬太尼0.015mg/kg加氟比洛芬酯100mg。各组均加生理盐水至100ml,持续输注量2ml/h。记录术后6、12、24、48h VAS评分、镇静评分、及不良反应的发生率。结果术后6、12、24,48h时A、C、D组的VAS显著低于B、组(p<0.05);术后6、12h时A组SS高于其他三组(p<0.05),12h后四组间的SS差异无统计学差异。A组恶心、呕吐的发生率显著高于其他三组(p<0.05)。结论小剂量芬太尼加入少量氯氨酮或者加入少量氟比洛芬酯静脉镇痛效果较好,且不良反应较少。     

Pharmaceutical care for patients with ischemic stroke: improving the patients quality of life

Objectives To improve patients health-related quality of life (HQL) after transient ischemic attack (TIA) or ischemic stroke; to guarantee an effective secondary prevention; to increase the patient’s satisfaction with recommendations regarding their medication by pharmacists. Setting Stroke Unit, neurological ward at the Klinikum Fulda, rehabilitation hospitals and community-based pharmacies in the region of Fulda, Germany. Method Patients with TIA or ischemic stroke were included. The patients were assigned to an intervention group (IG) or a control group (CG). The individual assignment of patients to IG or CG was based on the type of the local pharmacy to which patients belong. Community-based pharmacies either delivered standard care (CG) or provided additional intensified pharmaceutical care (PC; IG). Pharmacies delivering PC belong to a pre-existing “Quality Assurance Working Group” (QAWG). To evaluate the patient’s HQL, the Short Form-36 (SF-36) was used at study entry in hospital and at 12 months. The secondary prevention was documented at study entry in hospital and at 12 months. The patients’ satisfaction was measured by a questionnaire at the end of the study. Main outcome measures Patients’ HQL; secondary prevention; patients’ satisfaction with recommendations of the pharmacists with regards to their medication. Results Out of 1316 patients screened for participation in this study, 255 were recruited with 90/255 patients assigned to the IG and 165/255 patients assigned to the CG. During the study, the HQL of the patients in the IG did not change significantly. A significant decrease in the HQL was observed for the CG in 7/8 subscales and in both summary measures of the SF-36. After 12 months, 85.3% of the patients in the IG and 86.3% of the patients in the CG were treated with antiplatelet drugs or oral anticoagulants in accordance to treatment guidelines. Patients in the IG were significantly more satisfied with the individualized recommendations of the pharmacists than patients in the CG. Conclusion Our findings indicate that an intensified PC of patients after ischemic stroke by dedicated pharmacists may have a positive impact on HQL and patients’ satisfaction. PC in this study had no impact on adherence to secondary prevention medication.     

Interpersonal Processes of Care and Patient Satisfaction: Do Associations Differ by Race,Ethnicity, and Language?

Objective. Describe association of patient satisfaction with interpersonal processes of care (IPC) by race/ethnicity.
Data Sources/Study Setting. Interview with 1,664 patients (African Americans, English- and Spanish-speaking Latinos, and non-Latino Whites).
Study Design/Methods. Cross-sectional study of seven IPC measures (communication, patient-centered decision making, and interpersonal style) and three satisfaction measures (satisfaction with physicians, satisfaction with health care, and willingness to recommend physicians). Regression models explored associations, controlling for patient characteristics.
Principal Findings. In all groups: patient-centered decision making was positively associated with satisfaction with physicians ( B =0.10, p <.0001) and health care ( B =0.07, p <.001), and "recommend physicians" (OR=1.23, 95 percent CI 1.06, 1.43); discrimination was negatively associated with satisfaction with physicians ( B =0.09, p <.05) and health care ( B =0.17, p <.001). Unclear communication was associated with less satisfaction with physicians among Spanish-speaking Latinos. Explaining results was positively associated with all satisfaction outcomes for all groups with one exception (no association with satisfaction with physicians for Latino Spanish-speakers). Compassion/respect was positively associated with all outcomes for all groups with two exceptions (no association with satisfaction with health care among English-speaking Latinos and Whites).
Conclusions. All IPC measures were associated with at least one satisfaction outcome for all groups except for unclear communication.