芜湖市公立医院集团化改革实践与思考

分析了芜湖市组建医疗集团的背景、具体做法和取得的成效，从坚持公立医院公益属性、优化集团组织结构、完善服务体系建设、建立分级医疗机制提出了建议。     

我国县级公立医院改革关键问题与路径选择

自县级公立医院改革试点以来,在各领域都有所探索并形成初步的改革思路。但是,在改革中仍有不少关键问题未得到解决,诸如：改革的多元顶层设计思路、补偿机制的持续性与稳定性、地方政府财政压力加重、医院管理体制机制改革未能协同进行、调动和保障医务人员积极性的机制亟待完善、医疗服务定价无法体现医疗服务价值、人才队伍建设滞后、医保基金的使用等。建议下一步县级公立医院改革应在多元化、多层次的顶层设计指导下,坚持公益性与医院经营效益相结合,建立县级公立医院的现代医院管理制度。改革要从创新人力资本管理机制、完善破除“以药补医”后的补偿机制和配套措施、推进法人治理和政事分开、加强医保基金对居民医疗需求的引导、加快医院信息化建设等方向上寻求突破。     

区域中医医疗集团运行管理模式的实践与思考

通过组建区域中医医疗集团,探索公立医院改革和发展新模式。同时,为解决群众“看病难、看病贵”提供新思路。在区域中医医疗集团运行中实现以理事会为核心的治理结构,集团内部各成员单位的交流与合作进一步加强,在战略管理、技术交流、双向转诊、远程会诊系统等方面取得了显著成效。     

中小城市公立医院基础设施建设的必要性分析

公立医院改革是医药卫生体制改革方案确定的五项重点改革内容之一,中小城市公立医院是改革的重中之重。通过SWOT分析、统计数据分析和市场需求分析,进一步探讨中小城市公立医院建设的必要性,提出了优化资源配置、加强医院建设、合理医疗布局、完善服务体系对提高医疗服务的可及性和基层医疗服务能力具有积极的促进作用。     

我国公立医院改革进展、面临的挑战及展望

我国公立医院改革试点3年来,在各个改革领域都有所探索并形成初步思路。有的在重大体制机制改革和服务体系建设方面锐意创新、大胆探索,有的在便民惠民措施方面真抓实干、亮点频出,有的围绕调动医务人员积极性、鼓励多元化办医等方面认真履行、扎实推进。总体来说改革取得一定的进展、获得一定的成效、积累了一定的经验。但是,改革中仍存在不少困惑,体制机制改革未形成统一趋势、调动和保障医务人员积极性的机制亟待建立、医疗费用控制效果仍不明显,这些都为公立医院改革提出了挑战。下一步公立医院改革将从明确公立医院定位、制度机制设计等方向上寻求突破点。     

关于公立医院补偿机制改革的思考

从理论上分析了公立医院补偿模式的特点,以及政府卫生投入和医疗服务收费之间的关系;梳理了公立医院补偿机制存在的问题;提出了改革补偿机制的建议,即在政府按照医改要求足额投入,调整医疗服务价格的基础上,改革政府投入机制、医疗服务收入分配机制和医保支付方式,并建立有效的监管和奖惩体系。     

我国公立医院改革拓展与深化

文章总结了公立医院改革试点已取得的共识：（1）以改革支付方式为切入点;（2）破除以药补医、完善补偿机制为关键环节;（3）充分调动医务人员积极性;（4）强化管理、便民惠民,为改革创造良好环境;（5）实施多元化办医,满足不同医疗服务需求。进一步指出了尚需深化探索的领域。在此基础上,提出对已有的共识和措施应该在面上拓展,对尚未达成共识的应该深入研究。目前急需深入研究和探索的领域包括：公立医院治理结构改革、医院收入分配改革以及公立医院规模控制与体系建设。文章最后强调：公立医院改革是一项系统工程,只有有重点的、全面系统的实施改革试点才能实现改革的预期目标。     

完善公立医院补偿机制改革的难点与思考

补偿机制改革是公立医院改革的重点和难点。在分析当前公立医院财政补助现状以及取消药品加成的影响的基础上,指出当前补偿途径在具体实施过程中还存在相当的困难。为保障公立医院补偿机制改革的顺利推进,应从医疗服务的公平性和效益出发,明确补偿范围,制定补偿标准,并在机制体制上确保补偿到位。     

北京市公立医院法人治理结构改革的外部环境分析

从公立医院法人治理结构改革的市场环境、筹资支付系统和政府监管三方面探讨改革的动力和阻力。动力来自社会需求、医药卫生体制改革的目标和发展方向及医疗服务市场的完善,阻力来自于公立医院所处的市场地位,优质资源的不足和尚未理顺的管理体制和机制。

     

公立医院法人治理结构与改革

随着国务院医改近期重点实施方案的出台,公立医院法人治理结构的改革模式也渐渐明朗。公立医院法人治理结构改革是创新公立医院体制机制的关键任务之一,是维护公立医院公益性的重要制度保障。针对公立医院法人治理结构的内涵作了阐述,从公立医院的多层委托代理关系、产权制度等多角度分析了我国公立医院法人治理结构的现状和问题,提出了我国公立医院法人治理结构改革的具体措施。     

北京市市属医院患者满意度评价的探索及实践

患者满意度测评是评价医疗服务质量与医护人员工作绩效的有力工具。随着医改的深入,为科学评价新医改前期实施成效,北京市医院管理局制定医院患者满意度评价方案,并且积极推动评价方案的实施。实施结果显示,患者满意度评价对于指导医院改进,完善服务,构建和谐医患关系有重要的现实意义。     

糖尿病基层卫生适宜技术示范基地建设的实践探讨

针对基层医疗机构卫生服务技术水平和服务能力相对较低的现状,论述基层卫生适宜技术示范基地建设的重要性,并介绍糖尿病基层卫生适宜技术示范基地建设的经验以及取得的成效,为今后开展卫生适宜技术推广工作提供有益的借鉴。     

武警部队医院绩效考评体系的构建与实践

介绍了武警部队医院绩效考评体系的构建,介绍了医院绩效考评体系的设计思路和具体实施过程,分析了绩效考评工作实践和成效情况,并结合医院自身特点和运行机制改革,对照军队医院等级评审有关要求,对进一步完善综合绩效考评工作提出了建议,以期为军地医院绩效管理工作提供一定的参考和借鉴。     

关于我国公立医院经济效率的探讨

目的 分析我国公立医院的经济效率。方法 以总服务人次数为产出指标,以卫生技术人员数和政府投入金额为投入指标,分别使用柯布道格拉斯生产函数中的指数及相关系数代表技术效率与配置效率。结果 全国的整体技术效率为1.206,配置效率为1.659,东、中、西部分别为1.168、1.685,0.986、0.866,1.001、1.867。结论 整体技术效率高于各地区的技术效率,东、中、西部对比分析发现效率差异与经济发达程度关系不大。     

基层医疗机构人才队伍建设的探讨

??????? 在医改中硬件是基础,软件是根本,基层医疗机构人才队伍建设问题至关重要,本文就如何吸引毕业生下沉到基层、如何提升基层现存医疗队伍的技术水平提出建议,并为如何实现2020年培养30万名全科医生的总体目标,提出利用社会融资方法培养农村全科医生的构想。     

Rates of readmission and death associated with leaving hospital against medical advice: a population-based study

Background:

Leaving hospital against medical advice may have adverse consequences. Previous studies have been limited by evaluating specific types of patients, small sample sizes and incomplete determination of outcomes. We hypothesized that leaving hospital against medical advice would be associated with increases in subsequent readmission and death.

Methods:

In a population-based analysis involving all adults admitted to hospital and discharged alive in Manitoba from Apr. 1, 1990, to Feb. 28, 2009, we evaluated all-cause 90-day mortality and 30-day hospital readmission. We used multivariable regression, adjusted for age, sex, socioeconomic status, year of hospital admission, patient comorbidities, hospital diagnosis, past frequency of admission to hospital, having previously left hospital against medical advice and data clustering (patients with multiple admissions). For readmission, we assessed both between-person and within-person effects of leaving hospital against medical advice.

Results:

Leaving against medical advice occurred in 21 417 of 1 916 104 index hospital admissions (1.1%), and was associated with higher adjusted rates of 90-day mortality (odds ratio [OR] 2.51, 95% confidence interval [CI] 2.18–2.89), and 30-day hospital readmission (within-person OR 2.10, CI 1.99–2.21; between-person OR 3.04, CI 2.79–3.30). In our additional analyses, elevated rates of readmission and death associated with leaving against medical advice were manifest within 1 week and persisted for at least 180 days after discharge.

Interpretation:

Adults who left the hospital against medical advice had higher rates of hospital readmission and death. The persistence of these effects suggests that they are not solely a result of incomplete treatment of acute illness. Interventions aimed at reducing these effects may need to include longitudinal interventions extending beyond admission to hospital.Patients leaving hospital against medical advice have been discussed in the medical literature for more than 50 years.¹ Reported to occur in 1%–2% of patients in general hospitals,^2,3 the numbers are large; in the United States, 368 000 patients left against medical advice in 2007,³ and rates higher than 10% have been documented in certain subgroups, including Canadian patients with HIV and predominantly poor residents of inner city areas.^4,5 The main concern over leaving hospital against medical advice is that it may increase morbidity or mortality. Previous studies attempting to assess this effect^2,4–13 have all been restricted to specific types of patients, and most studies were limited by small sample sizes and incomplete determination of outcomes. In this study, we used data that avoided these limitations to test the hypothesis that patients who leave hospital against medical advice have higher rates of hospital readmission and death.     

Changes in ischemic stroke presentations,management and outcomes during the first year of the COVID-19 pandemic in Alberta: a population study

Background:Pandemics may promote hospital avoidance, and added precautions may exacerbate treatment delays for medical emergencies such as stroke. We sought to evaluate ischemic stroke presentations, management and outcomes during the first year of the COVID-19 pandemic.Methods:We conducted a population-based study, using linked administrative and stroke registry data from Alberta to identify all patients presenting with stroke before the pandemic (Jan. 1, 2016 to Feb. 27, 2020) and in 5 periods over the first pandemic year (Feb. 28, 2020 to Mar. 31, 2021), reflecting changes in case numbers and restrictions. We evaluated changes in hospital admissions, emergency department presentations, thrombolysis, endovascular therapy, workflow times and outcomes.Results:The study included 19 531 patients in the prepandemic period and 4900 patients across the 5 pandemic periods. Presentations for ischemic stroke dropped in the first pandemic wave (weekly adjusted incidence rate ratio [IRR] 0.54, 95% confidence interval [CI] 0.50 to 0.59). Population-level incidence of thrombolysis (adjusted IRR 0.50, 95% CI 0.41 to 0.62) and endovascular therapy (adjusted IRR 0.63, 95% CI 0.47 to 0.84) also decreased during the first wave, but proportions of patients presenting with stroke who received acute therapies did not decline. Rates of patients presenting with stroke did not return to prepandemic levels, even during a lull in COVID-19 cases between the first 2 waves of the pandemic, and fell further in subsequent waves. In-hospital delays in thrombolysis or endovascular therapy occurred in several pandemic periods. The likelihood of in-hospital death increased in Wave 2 (adjusted odds ratio [OR] 1.48, 95% CI 1.25 to 1.74) and Wave 3 (adjusted OR 1.46, 95% CI 1.07 to 2.00). Out-of-hospital deaths, as a proportion of stroke-related deaths, rose during 4 of 5 pandemic periods.Interpretation:The first year of the COVID-19 pandemic saw persistently reduced rates of patients presenting with ischemic stroke, recurrent treatment delays and higher risk of in-hospital death in later waves. These findings support public health messaging that encourages care-seeking for medical emergencies during pandemic periods, and stroke systems should re-evaluate protocols to mitigate inefficiencies.

In response to the COVID-19 pandemic, affected countries implemented various public health measures to decrease viral transmission. An unintended consequence of these measures could be hospital avoidance by patients with medical emergencies, as observed during other outbreaks in the 2000s.^1,2 Some public health messaging specifically warned groups at high cardiovascular risk, such as older people or those with heart disease, that they were at elevated risk of severe COVID-19.³ Physical distancing may also result in loss of services and support networks, impairing patients’ ability to seek medical assistance.⁴ Furthermore, pandemics generate new challenges of managing personal protective equipment and cleaning protocols,⁵ and additional information bottlenecks, which could result in workflow delays for emergencies like stroke.⁶Previous studies have reported declines in patients presenting to hospital with stroke or acute coronary syndrome during the pandemic.^7,8 A World Stroke Organization survey of members in several countries indicated a sharp reduction in stroke admissions by 50%–80% in the first weeks of the pandemic.⁹ A cross-sectional study reported a global decline in hospital admissions for stroke.¹⁰ Patients who present to hospital seem to be doing so later than usual, perhaps waiting until their condition becomes more severe.^11–14 However, studies have not been at a population level, consequently suffering from selection bias, and have generally focused only on the first wave of the pandemic. As the associations between the pandemic and the incidence, treatment, workflow and outcomes of stroke are likely to be modified by several events — including changing COVID-19 case counts, public health restrictions and health system strains — it is important to explore population data from pandemic periods beyond the first wave to better understand these phenomena.Verifying and quantifying the pandemic’s effect on stroke presentations and workflow can help tailor public health messaging to continue emphasizing the time-critical nature of emergencies like stroke. Such data may also help optimize pandemic stroke workflow protocols. We sought to explore patterns of hospital admissions, treatment rates, workflow delays and outcomes for ischemic stroke during the first year of the COVID-19 pandemic in Alberta, Canada.     

湖北省公立医院医护人员薪酬制度调查分析

目的 分析湖北省公立医院医护人员薪酬制度问题,提出解决策略。方法 以湖北省12家公立医院的1 155名医护人员为调查对象,利用描述性统计与χ²检验等方法对数据进行统计分析。结果 湖北省公立医院医护人员薪酬与市场价值背离;半数左右的医护人员认为薪酬制度不科学、不满意当前收入。结论 当前湖北省公立医院医护人员薪酬制度在一定程度上并不科学。     

医药价格综合改革形势下三甲公立医院运行机制变革

医药价格综合改革利国利民,需采取有效措施以保证改革顺利进行。在总结各地区医药价格综合改革做法基础上,结合某三甲公立医院改革前后运行数据,分析改革对三甲公立医院运行机制影响,并提出医药价格综合改革形势下三甲公立医院可持续发展的路径。     

Possible Environmental Origin of Resistance of Aspergillus fumigatus to Medical Triazoles

We reported the emergence of resistance to medical triazoles of Aspergillus fumigatus isolates from patients with invasive aspergillosis. A dominant resistance mechanism was found, and we hypothesized that azole resistance might develop through azole exposure in the environment rather than in azole-treated patients. We investigated if A. fumigatus isolates resistant to medical triazoles are present in our environment by sampling the hospital indoor environment and soil from the outdoor environment. Antifungal susceptibility, resistance mechanisms, and genetic relatedness were compared with those of azole-resistant clinical isolates collected in a previous study. Itraconazole-resistant A. fumigatus (five isolates) was cultured from the indoor hospital environment as well as from soil obtained from flower beds in proximity to the hospital (six isolates) but never from natural soil. Additional samples of commercial compost, leaves, and seeds obtained from a garden center and a plant nursery were also positive (four isolates). Cross-resistance was observed for voriconazole, posaconazole, and the azole fungicides metconazole and tebuconazole. Molecular analysis showed the presence of the dominant resistance mechanism, which was identical to that found in clinical isolates, in 13 of 15 environmental isolates, and it showed that environmental and clinical isolates were genetically clustered apart from nonresistant isolates. Patients with azole-resistant aspergillosis might have been colonized with azole-resistant isolates from the environment.Invasive aspergillosis is a fungal disease caused by Aspergillus species that primarily affects immunocompromised patients, such as those treated for hematological malignancy. Patients may become infected by inhalation of ambient air that contains fungal spores. The Aspergillus conidia can penetrate into the alveoli and if not effectively removed, may germinate, proliferate, and cause invasive aspergillosis. Mortality and morbidity due to invasive aspergillosis remain a significant problem.Triazoles, such as itraconazole (ITZ), voriconazole, and posaconazole, are used increasingly in the management of patients with this disease. Although the risk of resistance due to the increased use of triazoles is considered low (11), we recently observed ITZ resistance rapidly emerging in clinical Aspergillus fumigatus isolates (19, 22, 24, 25). Azole resistance was observed in up to 6% of patients in our hospital and in up to 14.5% of isolates sent to our laboratory from other hospitals in The Netherlands, which were obtained from patients with aspergillus disease (19). Furthermore, azole resistance has been reported in other European countries (3, 13, 19). The ITZ-resistant isolates also showed significantly reduced susceptibility to the other mold-active medical triazoles voriconazole and posaconazole (19). A substitution of leucine for histidine at codon 98 (L98H), combined with a 34-bp tandem repeat (designated TR) in the promoter region of the cyp51A gene (TR/L98H), which is the target for antifungal azoles, was found in 94% of isolates (14, 19, 24).Azole resistance can develop through the exposure of the fungus to azole compounds, which may occur in azole-treated patients or through the use of azole compounds in the environment. The dominance of a single resistance mechanism is difficult to explain by resistance development in individual azole-treated patients, as one would expect multiple resistance mechanisms to develop. Also, spread by person-to-person transmission of any Aspergillus isolate is highly unlikely. As inhalation of airborne aspergillus spores is the common route of infection for aspergillus diseases, we hypothesized that the dominance of a single resistance mechanism in clinical ITZ-resistant isolates was more consistent with acquisition from a common environmental source (19). If azole-resistant A. fumigatus is present in our environment, patients could inhale resistant spores and subsequently develop azole-resistant disease. Indeed, azole-resistant aspergillosis was reported in azole-naïve patients, indicating that resistance does not exclusively develop during azole therapy (24).Favorable conditions for resistance development are exposure to azole compounds and the presence of reproducing fungus (1). A. fumigatus is abundantly present in our environment as saprophytic, reproducing fungi, most notably in soil and compost. Furthermore, azoles are commonly used for plant protection as well as material preservation. Therefore, it appears that resistance development in A. fumigatus is feasible in the environment, and isolates that develop resistance to fungicides might be cross-resistant to medical triazoles.We investigated if A. fumigatus isolates that are present in our environment are resistant to medical triazoles and if they are cross-resistant to azole fungicides. Furthermore, we characterized the isolates by microsatellite typing in order to determine if they were genetically related to clinical A. fumigatus isolates previously obtained from patients cared for in our University Medical Center.