我国医疗联合体的利益相关者分析

随着医药卫生体制改革的不断深化,组建医疗联合体成为公立医院改革的新趋势。通过对医疗联合体利益相关者分析,组建区域性医疗联合体,对于联合体成员,包括核心医院和其他成员医院,还有政府或者患者都是有利的。因此,政府应在政策上对区域性医疗联合体给予更多支持,充分发挥医疗联合体的优势效应,促进公立医院的发展。     

Medical Need,Equality, and Uncertainty

Many hold that distributing healthcare according to medical need is a requirement of equality. Most egalitarians believe, however, that people ought to be equal on the whole, by some overall measure of well‐being or life‐prospects; it would be a massive coincidence if distributing healthcare according to medical need turned out to be an effective way of promoting equality overall. I argue that distributing healthcare according to medical need is important for reducing individuals' uncertainty surrounding their future medical needs. In other words, distributing healthcare according to medical need is a natural feature of healthcare insurance; it is about indemnity, not equality.     

Pitfalls in health communication: healthcare policy, institution, structure, and process

The state of health communication for a given population is a function of several tiers of structure and process: government policy, healthcare directives, healthcare structure and process, and the ethnosocial realities of a multicultural society. Common yet specific to these tiers of health communication is the interpersonal and intergroup use of language in all its forms. Language is the most common behavior exhibited by humankind. Its use at all tiers determines quality of healthcare and quality of life for healthcare consumers: patients and their families. Of note, at the consumer end, mounting evidence demonstrates that barriers to health communication contribute to poorer access to care, quality of care, and health outcomes. The lack of comprehensible and usable written and spoken language is a major barrier to health communication targeting primary and secondary disease prevention and is a major contributor to the misuse of healthcare, patient noncompliance, rising healthcare costs. In this paper, we cursorily examine the relationship among government policy, institutional directives, and healthcare structure and process and its influence on the public health, especially vulnerable populations. We conclude that limited health communication in the context of changing healthcare environments and diverse populations is an important underpinning of rising healthcare costs and sustained health disparities. More research is needed to improve communication about health at all tiers and to develop health communication interventions that are usable by all population groups.     

Stakeholders’ Perceptions on Shortage of Healthcare Workers in Primary Healthcare in Botswana: Focus Group Discussions

Background

An adequate health workforce force is central to universal health coverage and positive public health outcomes. However many African countries have critical shortages of healthcare workers, which are worse in primary healthcare. The aim of this study was to explore the perceptions of healthcare workers, policy makers and the community on the shortage of healthcare workers in Botswana.

Method

Fifteen focus group discussions were conducted with three groups of policy makers, six groups of healthcare workers and six groups of community members in rural, urban and remote rural health districts of Botswana. All the participants were 18 years and older. Recruitment was purposive and the framework method was used to inductively analyse the data.

Results

There was a perceived shortage of healthcare workers in primary healthcare, which was believed to result from an increased need for health services, inequitable distribution of healthcare workers, migration and too few such workers being trained. Migration was mainly the result of unfavourable personal and family factors, weak and ineffective healthcare and human resources management, low salaries and inadequate incentives for rural and remote area service.

Conclusions

Botswana has a perceived shortage of healthcare workers, which is worse in primary healthcare and rural areas, as a result of multiple complex factors. To address the scarcity the country should train adequate numbers of healthcare workers and distribute them equitably to sufficiently resourced healthcare facilities. They should be competently managed and adequately remunerated and the living conditions and rural infrastructure should also be improved.     

Healthcare Worker Contact Networks and the Prevention of Hospital-Acquired Infections

We present a comprehensive approach to using electronic medical records (EMR) for constructing contact networks of healthcare workers in a hospital. This approach is applied at the University of Iowa Hospitals and Clinics (UIHC) – a 3.2 million square foot facility with 700 beds and about 8,000 healthcare workers – by obtaining 19.8 million EMR data points, spread over more than 21 months. We use these data to construct 9,000 different healthcare worker contact networks, which serve as proxies for patterns of actual healthcare worker contacts. Unlike earlier approaches, our methods are based on large-scale data and do not make any a priori assumptions about edges (contacts) between healthcare workers, degree distributions of healthcare workers, their assignment to wards, etc. Preliminary validation using data gathered from a 10-day long deployment of a wireless sensor network in the Medical Intensive Care Unit suggests that EMR logins can serve as realistic proxies for hospital-wide healthcare worker movement and contact patterns. Despite spatial and job-related constraints on healthcare worker movement and interactions, analysis reveals a strong structural similarity between the healthcare worker contact networks we generate and social networks that arise in other (e.g., online) settings. Furthermore, our analysis shows that disease can spread much more rapidly within the constructed contact networks as compared to random networks of similar size and density. Using the generated contact networks, we evaluate several alternate vaccination policies and conclude that a simple policy that vaccinates the most mobile healthcare workers first, is robust and quite effective relative to a random vaccination policy.     

Redesigning healthcare: The 2.4 billion euro question?

Although it has been possible to transfer electrocardiograms via a phone line for more than 100 years, use of internet-based patient monitoring and communication systems in daily care is uncommon. Despite the introduction of numerous health-monitoring devices, and despite most patients having internet access, the implementation of individualised healthcare services is still limited. On the other hand, hospitals have invested heavily in massive information systems offering limited value for money and connectivity. However, the consumer market for personal healthcare devices is developing rapidly and with the current healthcare-related investments by tech companies it can be expected that the way healthcare is provided will change dramatically. Although a variety of initiatives under the banner of ‘e-Health’ are deployed, most are characterised by either industry-driven developments without proven clinical effectiveness or individual initiatives lacking the embedding within the traditional organisations. However, the introduction of numerous smart devices and internet-based technologies facilitates the fundamental redesign of healthcare based on the principle of achieving the best possible care for the individual patient at the lowest possible cost. Conclusion The way healthcare is delivered will change, but to what degree healthcare professionals together with patients will be able to redesign healthcare in a structured manner is still a question.     

Potential for industrial ecology to support healthcare sustainability: Scoping review of a fragmented literature and conceptual framework for future research

Healthcare is a critical service sector with a sizable environmental footprint from both direct activities and the indirect emissions of related products and infrastructure. As in all other sectors, the “inside‐out” environmental impacts of healthcare (e.g., from greenhouse gas emissions, smog‐forming emissions, and acidifying emissions) are harmful to public health. The environmental footprint of healthcare is subject to upward pressure from several factors, including the expansion of healthcare services in developing economies, global population growth, and aging demographics. These factors are compounded by the deployment of increasingly sophisticated medical procedures, equipment, and technologies that are energy‐ and resource‐intensive. From an “outside‐in” perspective, on the other hand, healthcare systems are increasingly susceptible to the effects of climate change, limited resource access, and other external influences. We conducted a comprehensive scoping review of the existing literature on environmental issues and other sustainability aspects in healthcare, based on a representative sample from over 1,700 articles published between 1987 and 2017. To guide our review of this fragmented literature, and to build a conceptual foundation for future research, we developed an industrial ecology framework for healthcare sustainability. Our framework conceptualizes the healthcare sector as comprising “foreground systems” of healthcare service delivery that are dependent on “background product systems.” By mapping the existing literature onto our framework, we highlight largely untapped opportunities for the industrial ecology community to use “top‐down” and “bottom‐up” approaches to build an evidence base for healthcare sustainability.     

Preventing fatal diseases increases healthcare costs: cause elimination life table approach.

OBJECTIVES: To examine whether elimination of fatal diseases will increase healthcare costs. DESIGN: Mortality data from vital statistics combined with healthcare spending in a cause elimination life table. Costs were allocated to specific diseases through the various healthcare registers. SETTING AND SUBJECTS: The population of the Netherlands, 1988. MAIN OUTCOME MEASURES: Healthcare costs of a synthetic life table cohort, expressed as life time expected costs. RESULTS: The life time expected healthcare costs for 1988 in the Netherlands were 56,600 Pounds for men and 80,900 Pounds for women. Elimination of fatal diseases--such as coronary heart disease, cancer, or chronic obstructive lung disease--increases healthcare costs. Major savings will be achieved only by elimination of non-fatal disease--such as musculoskeletal diseases and mental disorders. CONCLUSION: The aim of prevention is to spare people from avoidable misery and death not to save money on the healthcare system. In countries with low mortality, elimination of fatal diseases by successful prevention increases healthcare spending because of the medical expenses during added life years.     

Welfarism versus 'free enterprise': considerations of power and justice in the Philippine healthcare system

The just distribution of benefits and burdens of healthcare, at least in the contemporary Philippine context, is an issue that gravitates towards two opposing doctrines of welfarism and 'free enterprise.' Supported largely by popular opinion, welfarism maintains that social welfare and healthcare are primarily the responsibility of the government. Free enterprise (FE) doctrine, on the other hand, maintains that social welfare is basically a market function and that healthcare should be a private industry that operates under competitive conditions with minimal government control. I will examine the ethical implications of these two doctrines as they inform healthcare programmes by business and government, namely: (a) the Devolution of Health Services and (b) the Philippine Health Maintenance Organization (HMO). I will argue that these doctrines and the health programmes they inform are deficient in following respects: (1) equitable access to healthcare, (2) individual needs for premium healthcare, (3) optimal utilisation of health resources, and (4) the equitable assignment of burdens that healthcare entails. These respects, as considerations of justice, are consistent with an operational definition of 'power' proposed here as 'access to and control of resources.'     

In the patient's best interest--a call to action,a call to balance

Nurses, physicians, and other healthcare professionals often complain that a loss of freedom or other obstacles hinder their ability to act in the best interest of the patient. These barriers cause professional burnout and moral outrage, and may contribute to a migration away from medicine or, more broadly, healthcare. Understanding the historical underpinnings of the phrase "in the patient's best interest," and realizing that healthcare, which is fundamentally a moral enterprise must be built on sound business principles can help healthcare professionals reframe the issue, and reclaim their original commitment to a difficult path.     

A Taxonomic Review of the Use of IoT and Blockchain in Healthcare Applications

ObjectivesWith the rapid evolution and technology advancement, the healthcare sector is evolving day by day. It is taking advantage of different technologies such as Internet of things and Blockchain. Several applications related to daily healthcare activities are adopting the use of these technologies. In this paper, we present a review in which we group different healthcare applications that integrate the Internet of things and Blockchain in their systems.Material and methodsA review study about the integration of IoT and Blockchain in healthcare systems was conducted. We searched the databases ScienceDirect, IEEE Xplore, Google Scholar and ACM Digital Library.ResultsThis review focuses on categorizing the use cases of IoT and Blockchain in the healthcare sector. The study listed 6 applications in medical services, namely, remote patient monitoring, electronic medical records management, disease prediction, patient tracking, drug traceability and fighting infectious disease especially COVID-19. The paper also investigates the challenges associated with the adoption of the Blockchain technology in healthcare IoT-based systems and some of the existing solutions. It also introduces some future research directions.ConclusionThe survey of the use cases of IoT and Blockchain in the healthcare sector will serve as a state of the art for future researches. In addition, the paper gives some directions to new possible researches that could help to revolutionize the healthcare sector by using other technologies such as artificial intelligence, big data, fog and cloud computing.     

Smoking Behavior and Healthcare Expenditure in the United States, 1992–2009: Panel Data Estimates

BackgroundReductions in smoking in Arizona and California have been shown to be associated with reduced per capita healthcare expenditures in these states compared to control populations in the rest of the US. This paper extends that analysis to all states and estimates changes in healthcare expenditure attributable to changes in aggregate measures of smoking behavior in all states.ConclusionsChanges in healthcare expenditure appear quickly after changes in smoking behavior. A 10% relative drop in smoking in every state is predicted to be followed by an expected $63 billion reduction (in 2012 US dollars) in healthcare expenditure the next year. State and national policies that reduce smoking should be part of short term healthcare cost containment.     

Mapping out structural features in clinical care calling for ethical sensitivity: a theoretical approach to promote ethical competence in healthcare personnel and clinical ethical support services (CESS)

Clinical ethical support services (CESS) represent a multifaceted field of aims, consultancy models, and methodologies. Nevertheless, the overall aim of CESS can be summed up as contributing to healthcare of high ethical standards by improving ethically competent decision-making in clinical healthcare. In order to support clinical care adequately, CESS must pay systematic attention to all real-life ethical issues, including those which do not fall within the 'favourite' ethical issues of the day. In this paper we attempt to capture a comprehensive overview of categories of ethical tensions in clinical care. We present an analytical exposition of ethical structural features in judgement-based clinical care predicated on the assumption of the moral equality of human beings and the assessment of where healthcare contexts pose a challenge to achieving moral equality. The account and the emerging overview is worked out so that it can be easily contextualized with regards to national healthcare systems and specific branches of healthcare, as well as local healthcare institutions. By considering how the account and the overview can be applied to i) improve the ethical competence of healthcare personnel and consultants by broadening their sensitivity to ethical tensions, ii) identify neglected areas for ethical research, and iii) clarify the ethical responsibility of healthcare institutions' leadership, as well as specifying required institutionalized administration, we conclude that the proposed account should be considered useful for CESS.     

Chronic Non-Communicable Disease and Healthcare Access in Middle-Aged and Older Women Living in Soweto,South Africa

The aim of the current study was to describe the healthcare access, beliefs, and practices of middle-aged and older women residing in Soweto. This is a cross-sectional study of the primary (female) caregivers of the Birth to Twenty Cohort, based in Soweto, South Africa. The study instrument was administered to 1 102 caregivers as part of routine annual data collection. Over half the respondents (50.7%) reported having at least one chronic non-communicable disease (CND), only a small portion (33.3%) of whom reported accessing a healthcare service in the last 6 months. Reported availability of private medical practice and government clinics was high (75.1% and 61.5% respectively). The low utilisation of healthcare services by women with CND is a concern in terms of healthcare management. There is a need to further investigate how healthcare beliefs are formed, as well as the feasibility of programmes to support the ongoing management of CND in Soweto.     

Who Pays for Health Care in China? The Case of Heilongjiang Province

Background

Health spending by the Chinese government has declined and traditional social health insurance collapsed after economic reforms in the early 1980s; accordingly, the low-income population is exposed to potentially significant healthcare costs. Financing an equitable healthcare system represents a major policy objective in China’s current healthcare reform efforts. The current research presents an examination of the distribution of healthcare financing in a north-eastern Chinese province to compare equity status between urban and rural areas at two different times.

Methods

To analyze the progressivity of healthcare financing in terms of ability-to-pay, the Kakwani index was used to assess four healthcare financing channels: general taxes, social and commercial health insurance, and out-of-pocket payments. Two rounds of surveys were conducted in 2003 (11,572 individuals in 3841 households) and 2008 (15,817 individuals in 5530 households). Household socioeconomic status, healthcare payment, and utilization information were recorded using household interviews.

Results

China’s healthcare financing equity is unsound. Kakwani indices for general taxation were -0.0212 (urban) and -0.0297 (rural) in 2002, and -0.0097 (urban) and -0.0112 (rural) in 2007. Social health insurance coverage has expanded, however different financing distributions were found with respect to urban (0.0969 in 2002 vs. 0.0984 in 2007) and rural (0.0283 in 2002 vs. -0.3119 in 2007) areas. While progressivity of out-of-pocket payments decreased in both areas, the equity of financing was found to have improved among poorer respondents.

Conclusions

Overall, China’s healthcare financing distribution is unequal. Given the inequity of general taxes, decreasing the proportion of indirect taxes would considerably improve healthcare financing equity. Financial contribution mechanisms to social health insurance are equally significant to coverage extension. The use of flat rate contributions for healthcare funding places a disproportionate pressure upon the poor. Out-of-pocket payments have become equitable, but progressivity has decreased.     

Healthcare Failure Mode and Effects Analysis Under Fuzziness

Failure modes and effects analysis (FMEA) is a step-by-step approach for identifying all possible failures in a design, a manufacturing or assembly process, or a product or service. The purpose of the FMEA is to take actions to eliminate or reduce failures, starting with the highest-priority ones. This article presents a basis for prioritizing the healthcare problems using FMEA with linguistic variables and fuzzy if–then rules. Severity rating of healthcare problems is handled under the categories of catastrophic, major, moderate, and minor events. MATLAB 2007 is used to obtain the results of fuzzy if–then rules for prioritizing healthcare failures. A numerical example is given for four possible healthcare problems to be prioritized, which are wrong patient, delay in therapy, wrong analgesic selection, and wrong drug.     

Moral courage in medicine--disclosing medical error

Medical error is an inevitable occurrence that stresses the relationship between healthcare professionals and their patients. The number of errors is shocking; so too, is the revelation that few medical errors are routinely disclosed. When healthcare providers fail to inform patients of harm-causing medical error, then trust in the patient/provider relationship is broken and many ethical challenges surface. To successfully restore trust and perhaps lower liability costs, healthcare providers must avoid pointing fingers and adopt a policy of honesty and full disclosure.     

Counseling on cardiovascular behavioral risk factors within the healthcare system: the CroHort study

Eliminating four behavioral risk factors (tobacco use, physical inactivity, unhealthy diet and harmful use of alcohol) could contribute to a decrease of up to 80% in burden of non-communicable diseases, including cardiovascular diseases. Primary healthcare providers have a unique position within the healthcare system, which allows them to actively contribute to the prevention of cardiovascular behavioral risk factors (CVBRFs) by providing individual counseling. The aim of this article is to show the change in frequency and the effects of counseling on CVBRFs by healthcare providers between two periods: up until 2003 and between 2003 and 2008. Results, obtained within the CroHort study, show a low frequency and undesired effects of counseling within the healthcare system in both studied periods. This points to a lack of consistency with which the healthcare system tackles prevention of behavioral risk factors for cardiovascular diseases.     

Quality of oral health services in residential care: towards an evaluation framework

Background: There is widespread neglect of oral healthcare, and uncertainty about how best to organise and evaluate the impact of oral health services in long‐term care (LTC) facilities. Consequently, there is need for an evaluation framework to improve and account for the quality of oral healthcare in the facilities. Objectives: This paper: (i) identifies basic concepts of quality of care and evaluation in healthcare; (ii) reviews the methods used to evaluate the operation and effectiveness of oral healthcare in LTC facilities and (iii) recommends change to assure oral health‐related quality and accountability for frail elders. Method: A literature review provided insights to the theoretical basis and practical applications for assessing the quality of healthcare relevant to oral healthcare for frail elders. Results: Oral health‐related programmes in LTC facilities could be improved by using a combination of quality assurance and health programme evaluation that: (i) engages everyone involved; (ii) seeks multiple attributes of quality; (iii) evaluates the structure, process or activities, and outcome of the oral health programme; (iv) uses formative and summative methods to provide both quantitative and qualitative evidence of care and (v) transfers new knowledge for appropriate consideration and action. Conclusions: This theoretical framework can be applied in dentistry in LTC to provide an assessment model specific to oral healthcare for frail elders in residential care.     

医务人员手卫生监测结果回顾性分析及对策

目的了解医务人员手部卫生状况,制定改进措施,预防医院感染。方法回顾性分析东南大学附属中大医院2007年1月至2010年12月医务人员手卫生监测资料1586份。结果医护手监测合格率为89．28％,医生手监测合格率为86．94％,护士手监测合格率为93．09％;重点病区医护手监测台格率为91．98％,普通病区医护手监测合格率为87．06％;该院医护手监测合格率为90．64％,进修、实习医护手监测合格率为88．17％,手部检出细菌184株,葡萄球菌属占49．46％,阳性杆菌占14．67％。结论医务人员对手的清洁与消毒仍缺乏足够的认识,应加强医务人员手卫生培训与监督,提高医务人员手卫生合格率。