27家医院医疗纠纷发生率和赔付情况调查

目的 了解我国二、三级医疗机构医疗纠纷的发生水平、解决方式及赔偿情况,为公立医院医疗纠纷的解决和医疗责任的赔付模式的建立提供科学依据。方法 通过整群抽样选取山西、河北、福建、黑龙江、北京5个省市二、三级27所公立医院,采用统一的问卷调查方式,分别对二、三级医院2011—2013年的基本情况、医疗纠纷发生及医疗责任赔偿等进行调查分析。结果 二、三级医院百名医生医疗纠纷发生率分别为7.96和4.85,医疗纠纷非诉讼解决方式分别是92.72%和82.58%,医疗保险赔偿额分别占赔偿总额29.35%和24.41%。结论 目前我国仍处于医疗纠纷高发期, 医疗纠纷解决的主要途径是非诉讼解决方式,医疗责任的赔付主要来源是医院赔偿。     

我国目前妥善处理医疗纠纷面临的三个关键问题

通过分析我国目前医疗纠纷的实际状况,得出妥善处理医疗纠纷面临的3个关键问题：法律体系的科学统一;执法过程的公平公正;建立健全医疗损害责任保险制度并纳入法制管理轨道。     

医疗责任险在医院开展10年的效果评析与思考

北京协和医院已开展近10年医疗责任险,其在分散和转移医疗风险方面取得了一定成效。然而结合医院运行数据,医疗责任险仍然存在投保额高、赔偿少、回款慢、限制多、程序繁琐,保险抗风险能力与医院投保初衷相分离等问题。基于此,提出建立医疗机构与医务人员分别投保医责险的制约机制、推动建立强制性医疗责任保险、建立医疗纠纷“保险—调解—评估—理赔”四位一体快速解决机制等建议。     

对我国医疗损害鉴定制度的思考

医疗鉴定是医疗损害赔偿案件中法官确认医方是否承担医疗损害责任的关键环节,其鉴定结论直接关系到法官能否公正裁判案件、合理化解医疗纠纷。从医疗事故技术鉴定与医疗过错司法鉴定两个方面分析,提出对我国医疗鉴定制度的相关建议和设想。     

医疗纠纷的原因分析与对策

医疗纠纷是指发生在医患之间的,因病人对医务人员或医疗机构的医疗服务不满引起的对医方的争议。据报道,大部分纠纷并非真正由医疗事故、差错造成的。随着医学模式的转变和司法制度日益健全,人们的法制观念也不断增强,医疗纠纷是在《医疗事故处理条例》出台后,加之新闻媒体对医疗纠纷的备加关注,更成为社会舆论的焦点。就医疗机构而言,病人对医疗护理工作提出了新的越来越高的要求,几乎成为困扰医护人员的难题。为了解决这些棘手问题,提高病人对医疗工作的满意度,本文对多年来在工作中发生的医疗纠纷进行了原因分析,并提出了解决对策,目的是为了使医患关系和谐,利于临床工作。     

公益化视角下公立医院社会责任体系构建

公立医院是我国医疗服务的主体,同时也是社会责任的必然承担者。公益化视角下公立医院在获取自身生存和发展的同时,应最大程度地承担起“救死扶伤、生命至上”的社会责任新内涵。公立医院社会责任缺失与医疗市场越位、政府补偿缺位及医务人员宗旨意识错位有关。公益化视角下公立医院社会责任体系重建要改革公立医院运行机制、统筹利用社会各方力量、积极营造社会责任的文化氛围、提高医院综合管理水平及建立基于公益性的绩效考核方案。因此,要发挥公立医院社会责任要正确认识公立医院社会责任本质,应正确处理好社会责任与经营性之间的关系及充分发挥公立医院社会责任的利益相关方力量。有关企业社会责任及治理结构的理论和方法对研究医院相关问题有重要借鉴作用,但不能照搬,中国经济、管理和卫生领域专家在公立医院社会责任及实现机制方面的探索还有许多工作要做。     

野生动物肇事公众责任保险发展困境与优化路径

野生动物肇事公众责任保险自开展以来, 存在着保险实施效果较差、承保机构参与不积极、保险范围难以扩大等问题, 在有效缓解人兽矛盾方面表现欠佳, 阻碍了生物多样性保护的落实与执行。本文以现阶段实施该保险的云南、西藏、浙江、四川为例梳理其应用模式, 并对具体地区的保险模式进行比较分析。研究表明, 野生动物肇事公众责任保险陷入发展困境的主要原因是产品设计不科学、财政经费不充足、政策制度不健全和保险体系不完善。建议优化保险要素设计、扩展经费来源渠道、健全配套政策法规, 建立政府主导、多方参与的中央财政补贴野生动物肇事公众责任保险体系, 该保险体系对于解决人兽冲突、支持生物多样性的保护、建立地球生命共同体具有重要的价值与意义。     

我国医疗责任保险的发展现状及对策研究

从20世纪90年代开始,医疗责任保险作为降低和分散医疗职业风险的重要手段之一逐步在我国各地试行。在调节医患关系中发挥了一定的作用,但就我国医疗责任保险发展现状而言还处于发展阶段,仍然存在许多问题。本文将从我国医疗保险发展现状入手,分析其产生问题的原因并尝试提出相关对策。     

信息不对称下公立医院过度医疗的治理

过度医疗作为医疗实践中的不良现象,是引发医疗纠纷和“看病贵”的重要原因。文章从信息不对称的角度,通过分析我国公立医院过度医疗治理现状,找出当前我国公立医院过度医疗治理存在的问题,提出信息不对称下公立医院过度医疗的治理模式,以期从根本上遏制公立医院过度医疗问题的发生。     

医疗责任与技术甄别机制在医疗纠纷管理中的应用

创新性采用医疗责任与技术甄别机制,回顾性对近5年82例医疗纠纷或不良事件进行系统甄别,不仅对医疗制度缺陷进行了甄别分析,提出改进策略,还对与司法鉴定结论不同的案例给予内部纠正,保证医疗技术持续开展。     

ANCESTRAL CHARACTER ESTIMATION UNDER THE THRESHOLD MODEL FROM QUANTITATIVE GENETICS

Evolutionary biology is a study of life's history on Earth. In researching this history, biologists are often interested in attempting to reconstruct phenotypes for the long extinct ancestors of living species. Various methods have been developed to do this on a phylogeny from the data for extant taxa. In the present article, I introduce a new approach for ancestral character estimation for discretely valued traits. This approach is based on the threshold model from evolutionary quantitative genetics. Under the threshold model, the value exhibited by an individual or species for a discrete character is determined by an underlying, unobserved continuous trait called “liability.” In this new method for ancestral state reconstruction, I use Bayesian Markov chain Monte Carlo (MCMC) to sample the liabilities of ancestral and tip species, and the relative positions of two or more thresholds, from their joint posterior probability distribution. Using data simulated under the model, I find that the method has very good performance in ancestral character estimation. Use of the threshold model for ancestral state reconstruction relies on a priori specification of the order of the discrete character states along the liability axis. I test the use of a Bayesian MCMC information theoretic criterion based approach to choose among different hypothesized orderings for the discrete character. Finally, I apply the method to the evolution of feeding mode in centrarchid fishes.     

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.     

Regressive logistic models for familial diseases: a formulation assuming an underlying liability model

Statistical models have been developed to delineate the major-gene and non-major-gene factors accounting for the familial aggregation of complex diseases. The mixed model assumes an underlying liability to the disease, to which a major gene, a multifactorial component, and random environment contribute independently. Affection is defined by a threshold on the liability scale. The regressive logistic models assume that the logarithm of the odds of being affected is a linear function of major genotype, phenotypes of antecedents and other covariates. An equivalence between these two approaches cannot be derived analytically. I propose a formulation of the regressive logistic models on the supposition of an underlying liability model of disease. Relatives are assumed to have correlated liabilities to the disease; affected persons have liabilities exceeding an estimable threshold. Under the assumption that the correlation structure of the relatives' liabilities follows a regressive model, the regression coefficients on antecedents are expressed in terms of the relevant familial correlations. A parsimonious parameterization is a consequence of the assumed liability model, and a one-to-one correspondence with the parameters of the mixed model can be established. The logits, derived under the class A regressive model and under the class D regressive model, can be extended to include a large variety of patterns of family dependence, as well as gene-environment interactions.     

Charitable giving as a signal of trustworthiness: Disentangling the signaling benefits of altruistic acts

It has been shown that psychological predispositions to benefit others can motivate human cooperation and the evolution of such social preferences can be explained with kin or multi-level selection models. It has also been shown that cooperation can evolve as a costly signal of an unobservable quality that makes a person more attractive with regard to other types of social interactions. Here we show that if a proportion of individuals with social preferences is maintained in the population through kin or multi-level selection, cooperative acts that are truly altruistic can be a costly signal of social preferences and make altruistic individuals more trustworthy interaction partners in social exchange. In a computerized laboratory experiment, we test whether altruistic behavior in the form of charitable giving is indeed correlated with trustworthiness and whether a charitable donation increases the observing agents' trust in the donor. Our results support these hypotheses and show that, apart from trust, responses to altruistic acts can have a rewarding or outcome-equalizing purpose. Our findings corroborate that the signaling benefits of altruistic acts that accrue in social exchange can ease the conditions for the evolution of social preferences.     

A comparative method for both discrete and continuous characters using the threshold model

The threshold model developed by Sewall Wright in 1934 can be used to model the evolution of two-state discrete characters along a phylogeny. The model assumes that there is a quantitative character, called liability, that is unobserved and that determines the discrete character according to whether the liability exceeds a threshold value. A Markov chain Monte Carlo algorithm is used to infer the evolutionary covariances of the liabilities for discrete characters, sampling liability values consistent with the phylogeny and with the observed data. The same approach can also be used for continuous characters by assuming that the tip species have values that have been observed. In this way, one can make a comparative-methods analysis that combines both discrete and continuous characters. Simulations are presented showing that the covariances of the liabilities are successfully estimated, although precision can be achieved only by using a large number of species, and we must always worry whether the covariances and the model apply throughout the group. An advantage of the threshold model is that the model can be straightforwardly extended to accommodate within-species phenotypic variation and allows an interface with quantitative-genetics models.     

Models of comorbidity for multifactorial disorders.

We develop several formal models for comorbidity between multifactorial disorders. Based on the work of D. N. Klein and L. P. Riso, the models include (i) alternate forms, where the two disorders have the same underlying continuum of liability; (ii) random multiformity, in which affection status on one disorder abruptly increases risk for the second; (iii) extreme multiformity, where only extreme cases have an abruptly increased risk for the second disorder; (iv) three independent disorders, in which excess comorbid cases are due to a separate, third disorder; (v) correlated liabilities, where the risk factors for the two disorders correlate; and (vi) direct causal models, where the liability for one disorder is a cause of the other disorder. These models are used to make quantitative predictions about the relative proportions of pairs of relatives who are classified according to whether each relative has neither disorder, disorder A but not B, disorder B but not A, or both A and B. For illustration, we analyze data on major depression (MD) and generalized anxiety disorder (GAD) assessed in adult female MZ and DZ twins, which enable estimation of the relative impact of genetic and environmental factors. Several models are rejected--that comorbid cases are due to chance; multiformity of GAD; a third independent disorder; and GAD being a cause of MD. Of the models that fit the data, correlated liabilities, MD causes GAD, and reciprocal causation seem best. MD appears to be a source of liability for GAD. Possible extensions to the models are discussed.     

Agonistic Behavior in Nesting Iguanas: A Stochastic Analysis of Dispute Settlement Dominated by the Minimization of Energy Cost

Competition within biological populations frequently leads to physical disputes. Natural selection requires that the costs of these disputes to the involved individuals are in some sense minimized. We examine a specific situation in detail, disputes between gravid female iguanas for nesting sites, and show that it is energy costs which are minimized and that this minimization is achieved by escalating the energy expended during the individual dispute and by the use of displays. The analysis uses probabilistic and information theoretic techniques.     

地市级医院医联体建设的实践探索

介绍了福建省南平市第一医院以紧密托管型模式开展区域医联体建设的主要做法,即坚持政府主体责任、创新工作机制、强化组织体系建设、设立政府托管基金等,探索在医改中处于夹心层的地市级城市医院医联体建设工作方式。