四川省内异地就医联网结算管理实践探索

四川省内基本医疗保险异地就医联网结算试点工作已全面启动。四川省肿瘤医院作为首批联网试点医院,积极顺应联网结算需求,主动创新、完善服务内涵、畅通服务流程,全面落实了实现异地就医即时结算的主要措施,极大方便了异地就医人群,取得了显著的社会效益。异地就医联网结算是一项全新工作,针对运行中存在的问题提出建议,为完善异地医保的服务与管理提供参考。     

基于远程医疗的异地转诊就医一体化实践探索

为探索借助远程医疗解决异地转诊就医一体化的问题，为异地转诊就医患者提供医疗保障。某医院成立专科疾病医联体，借助远程医疗对异地转诊就医患者提供医疗服务，总结某医院借助远程医疗，以专科疾病医联体进行精准转诊、异地就医，提供医疗保障的实践经验。某医院借助远程医疗，以专科疾病医联体为抓手，制定了精准转诊的规章制度，为异地就医患者提供了更加方便快捷的服务，同时降低了医疗费用，节省了医疗基金的开支，实践效果显著。借助远程医疗，成立专科疾病医联体，可以很好的实现患者精准转诊、精准医疗，解决异地就诊患者“看病难、看病贵”问题，为异地就医患者提供更好的医疗保障，助推实现全国异地就医一体化的大健康战略。     

按项目支付方式对恶性肿瘤参保患者住院费用的影响分析

目的 通过分析按项目支付的3个城市恶性肿瘤患者住院费用,探索不同医疗保险管理方式对恶性肿瘤治疗费用的影响。方法 从北京、上海、郑州市医保数据库中各随机抽取恶性肿瘤医保患者600名,统计分析其住院费用及其影响因素,并用多元线性回归模型分析次均住院费用的影响因素。结果 不同的管理方式对住院费用产生一定的影响,从而对住院费用有不同程度的影响。结论 在制定医保管理方法时,不仅要考虑控费效果,还应保障患者合理的就医需要;多种结算方式的综合应用可弥补单一结算方式的不足。     

德国医疗保险制度对我国统筹发展的借鉴与思考

目的 研究德国对于医疗保险制度统筹和不同体制整合衔接方面的成功经验,为我国医疗保险制度的统筹发展积累经验。方法 选取了德国作为个案,通过对其制度发展历程的论述和剖析。结果 德国的医疗保险制度整合相对成熟,在政策管理、支付结算、筹资管理等方面都有宝贵的经验。结论 德国医疗保险制度的成功发展的经验和教训对我国医疗保险制度的统筹发展具有借鉴意义,如异地就医制度、医疗服务一体化等,同时引发对我国医疗保险制度发展的深刻思考。

     

实施“先诊疗后结算”模式的医院财务内部控制

“先诊疗、后结算”服务模式是指就医者在门急诊诊疗时，可先预存押金，不必在接受每项诊疗服务时单独缴费，待所有诊疗过程结束后再统一结算。从财务的角度，详细阐述了新模式下财务的探制点及应采取的内控措施，以保证医院账款的安全，从而使新服务模式得以顺利推行。     

患者就医参与行为实证研究：基于成都市的调查

患者就医全过程参与是客观存在的,研究涵盖了患者就医过程中所传出的、与医疗活动相关的身心投入与努力。文章采用问卷调查方式收集数据,研究患者就医参与行为特征。结果表明,患者就医参与行为包括4个维度：患者参与患者安全行为、遵医配合行为、就医前信息搜集行为以及医患互动交流行为。同时分析了不同人口学背景下的患者在就医参与行为4个维度方面的异同。     

基于分级诊疗视角的就医行为分析及相关策略研究

通过国内外相关文献资料的患者门诊就医行为分析和研究,发现并总结出患者就医行为的影响因素、不同病种和不同人群的就医流向趋势。其研究结果可为我国分级诊疗的基层首诊、双向转诊等相关政策的制订和完善提供较为准确的理论依据,以促进分级诊疗的健康发展。     

我院实施“无障碍就医”的做法与成效

自2013年开始,青岛大学医学院附属医院实施“无障碍就医”以来,医院在各个方面都取得了显著成效。文章通过对“无障碍就医”工程实施的动因、意义、主要做法和成效进行剖析,为公立医院探索内部管理方式改革,实现患者便捷就医、安全就医的目标,缓解群众“看病难、看病贵”问题提供了有益的借鉴。     

塑造妇幼保健院智慧门诊的设想与探索

基于“云”“大”“物”“移”“智”信息技术，提出了妇幼保健智慧门诊的设想，对以信息集成平台为基础，由五大业务应用系统组成的智慧门诊信息系统构架进行了阐述，讨论了在预约挂号、就诊检查、诊间结算、充值缴费、结果的单次门诊就诊闭环中优化流程、提高效率、改善就医体验等方面的方法。     

基于门诊多类型就诊卡模式的数字化医院建设探讨

提出并实现了基于“三卡通”(医保卡、就诊卡、银行借记卡)支付的医院门诊就医新模式,从而进一步改善门诊就医环境,便捷就医流程,缓解群众“就医难”的问题,提升医院的财务管理水平和医疗服务质量,推进数字化医院建设。     

基于成本核算的医院内部服务价格的制定

随着医院内部成本核算基础工作的日益加强和成本核算体系的日趋成熟,为了使单位内部责任的划分更加清晰明确,把责任成本作为成本控制的重要内容纳入总体绩效考核评价体系中,实行内部服务价格势在必行。以成本核算为基础,探讨医院内部服务价格制定的作用、原则和方法,并以某大型三甲医院机电维修内部服务价格的制定为例,研究内部服务价格的制定步骤和实施环节。     

台湾地区全民健保总额预算制度设计与运行效果评述

总额预算制作为医保对供方主要支付方式之一在国际上得到广泛应用,我国的上海、北京等地区也开始在不同程度上通过总额预算方式实现支付方式改革。总额预算作为一种控制医疗费用过快增长的方式既有优势也存在弊端。以我国台湾地区为例,介绍总额预算制度的运行机制和总额制定方式,并探讨总额预算制的实施效果,分析总额预算达到效果最优化的制度设计,为改革提供政策借鉴。     

农村高血压患者协调性和连续性服务的利用现状研究

目的 分析高血压患者在农村医疗服务网络接受协调性和连续性服务的提供状况,为改进患者的整合服务利用提供决策参考。方法 根据国内外文献,以自行编制服务协调性和连续性提供的问卷为工具,调查数据采用描述性统计分析。结果 49.6%的患者伴有1种及以上疾病,约73.0%在乡镇卫生院有就医经历,到过2家及以上机构就医的占51.3%;在乡村两级治疗效果不佳的患者,能够获取村医和乡镇医生推荐转诊机构的比重最大,分别为28.4%和68.7%;上级医生能够根据下级机构相关诊疗信息连续诊疗的不到43.0%,下级医生能够根据前期诊疗信息继续诊疗的比例刚超4成;“上转容易、下转难”现象同样存在。 结论 农村慢性病患者的患病特点增加了在农村纵向医疗机构就诊的几率,但该网络提供连续性和协调性服务的程度却不高,应加强农村三级医疗机构间的全面整合。     

The effectiveness of words: Religion and healing among the Lubavitch of Stamford Hill

Testimonials of miraculous healing offered by Lubavitch Hasidim evoke images of exile and restitution which derive from Kabbalistic texts. Mediated practically through the person of the Rebbe, these testimonials articulate both immediate affliction and ultimate meaning, physical embodiment as well as symbolic representation, each constituting the other. Both Kabbalah and medical anthropology attempt to transcend not dissimilar epistemological dualisms: those characteristic of monotheism and contemporary science. Yet the lower root of Kabbalah affirms a material reality known through immediate sensory experience which recalls the rationale of biomedicine.     

Variation of a test’s sensitivity and specificity with disease prevalence

Background:

Anecdotal evidence suggests that the sensitivity and specificity of a diagnostic test may vary with disease prevalence. Our objective was to investigate the associations between disease prevalence and test sensitivity and specificity using studies of diagnostic accuracy.

Methods:

We used data from 23 meta-analyses, each of which included 10–39 studies (416 total). The median prevalence per review ranged from 1% to 77%. We evaluated the effects of prevalence on sensitivity and specificity using a bivariate random-effects model for each meta-analysis, with prevalence as a covariate. We estimated the overall effect of prevalence by pooling the effects using the inverse variance method.

Results:

Within a given review, a change in prevalence from the lowest to highest value resulted in a corresponding change in sensitivity or specificity from 0 to 40 percentage points. This effect was statistically significant (p < 0.05) for either sensitivity or specificity in 8 meta-analyses (35%). Overall, specificity tended to be lower with higher disease prevalence; there was no such systematic effect for sensitivity.

Interpretation:

The sensitivity and specificity of a test often vary with disease prevalence; this effect is likely to be the result of mechanisms, such as patient spectrum, that affect prevalence, sensitivity and specificity. Because it may be difficult to identify such mechanisms, clinicians should use prevalence as a guide when selecting studies that most closely match their situation.Diagnostic accuracy plays a central role in the evaluation of medical diagnostic tests. Test accuracy may be expressed as sensitivity and specificity, as positive and negative predictive values or as positive and negative likelihood ratios.¹ Some feel that the positive and negative predictive values of a test are more clinically relevant measures than sensitivity and specificity. However, predictive values directly depend on disease prevalence and can therefore not directly be translated from one situation to another.² In contrast, a test’s sensitivity and specificity are commonly believed not to vary with disease prevalence.^3–5Stability of sensitivity and specificity is an assumption that underlies the use of Bayes theorem in clinical diagnosis. Bayes theorem can be applied in clinical practice by using the likelihood ratio of a test and the probability of the disease before the test was done (pretest probability) to estimate the probability of disease after the test was done.² Because likelihood ratios are a function of sensitivity and specificity, it is assumed that the likelihood ratios also remain the same when prevalence varies.A number of studies have shown that sensitivity and specificity may not be as stable as thought.^6–10 We previously summarized the possible mechanisms through which differences in disease prevalence may lead to changes in a test’s sensitivity and specificity.¹⁰ Prevalence affects diagnostic accuracy because of clinical variability or through artifactual differences, as described in the theoretical framework in 6^,7 Artifactual differences can result from using additional exclusion criteria, verification bias or an imperfect reference standard. For example, using an imperfect reference standard may lead to an underestimate of diagnostic accuracy, but as prevalence increases, the extent to which this happens will vary.^8,9

Table 1:

Theoretical framework of how disease prevalence and test accuracy may be related¹⁰

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.     

皮肤病专科医院电子病历的设计与应用

???????目的 研究与开发具有皮肤病专科特色的电子病历系统,以实现皮肤科病人医疗信息的采集、加工、存储、传输和服务。方法 以windows sqlserver2005为后台数据库,以XML、C#为开发语言,建立皮肤病结构化病历。结果 该系统运行良好,安全稳定、易维护、通用性好。有效地提高了医生书写病历的速度和质量,并具有皮疹数码照片嵌入等功能。结论 本研究实现了具有皮肤病专科特色的电子病历系统,值得皮肤病医院推荐使用。     

Limited prospecting behaviour of juvenile Eagle Owls Bubo bubo during natal dispersal: implications for conservation

Capsule Features of the breeding population and temporary settlement area influence the behaviour of Eagle Owls Bubo bubo prospecting for breeding sites during natal dispersal.

Aims To understand how prospecting behaviour during natal dispersal is affected by (i) the main characteristics of the breeding and dispersing portions of the population and (ii) main prey availability.

Methods We explored the ten-year dynamics and characteristics of radio-tagged breeders and dispersers of an Eagle Owl population.

Results During the first years following natal dispersal there was little prospecting behaviour of nesting sites and birds remained mainly within non-breeding settlement areas, bordering the sector occupied by the breeding population. Settlement areas had an abundant food supply, and low intraspecific competition and mortality. We suggest that these features of the settlement areas may reduce the willingness of individuals to search for breeding sites and may have the potential to impact on the viability of breeding populations.

Conclusion From a conservation perspective, the lengthy use of the temporary settlement areas by juvenile Eagle Owls suggests that the sites should be considered as important as the breeding areas when planning conservation strategies. Reducing juvenile mortality in settlement areas may represent an overlooked conservation strategy for long-lived species and may have a crucial effect on the viability some animal populations.     

A special issue of Biophysical Reviews dedicated to the 20th IUPAB (virtual) Congress “in” Foz do Iguaçu

The 20th IUPAB Congress took place online, together with the annual meetings of the Brazilian Biophysical Society and the Brazilian Society for Biochemistry and Molecular Biology, from the 4th to the 8th of October, 2021. The ten keynote lectures, 24 symposia, two poster sessions, and a series of technical seminars covered the full diversity of current biophysical research and its interfaces with other fields. The event had over 1000 attendees, with an excellent gender balance. Although the Americas dominated, there were also significant numbers of participants from Europe, Asia, and Africa.

The International Union of Pure and Applied Biophysics (IUPAB) came into existence in Stockholm in 1961 and has been a member of the International Science Council since 1966 (Solomon 1968). Its overall objectives aim to foster international collaboration in all aspects of biophysics and related areas and to catalyze the advancement of basic biophysical research as well as its many applications. Although IUPAB is active on many fronts, undeniably one of its showcase events is the IUPAB Congress, traditionally organized every three years in different locations worldwide. In 2021, the event was organized and run from Brazil, albeit for the very first time in a virtual format due to travel restrictions imposed by the COVID-19 pandemic. On this occasion, the Congress was organized in conjunction with the annual meetings of both the Brazilian Biophysical Society (SBBf, in its 45th edition) and the Brazilian Society for Biochemistry and Molecular Biology (SBBq, in its 50th edition). Even with the united forces of these well-established local societies, it turned out to be a bumpy ride to bring the event to fruition.Plans for the 20th Congress began in 2016, almost immediately after the decision to hold the event in Brazil, a cause championed by the then-president of the Brazilian Biophysical Society, Marcelo Morales. The original plans had the meeting to be held in the Cidade Maravilhosa (The Wonderful City) of Rio de Janeiro in October 2020. However, it soon became apparent that the political and economic difficulties that the State of Rio was facing at the time meant that it would be wise to search for an alternative venue. The previous experience of SBBq in organizing similar events in the city of Foz do Iguaçu, on the borders with Argentina and Paraguay, made this an obvious choice. Furthermore, the natural attraction of the spectacular Iguaçu waterfalls seemed to be an ideal compensation for Sugar Loaf Mountain, Copacabana beach, and the statue of Christ the Redeemer on Corcovado Mountain.Then came the pandemic. By mid-2020, it had become apparent that there were too many unknowns to make it possible to proceed with an in-person event in October of that year. It was decided to postpone the congress to 2021 but with a firm belief that things would be “back to normal.” Sweet delusion! As 2020 turned into 2021 and the severity and longevity of the pandemic became clearer and clearer (not to mention the abysmal performance of the Brazilian government in failing to rise to the challenge), the inevitable decision was taken to transform the event into an “on-line” congress. This was a first for both the local organizers and the IUPAB.The move to an online format immediately had an impact on the organization of the Young Scientist Program. This was initially envisaged to be a combination of formal and informal activities aimed at uniting about 40 early carrier scientists and post-docs for a couple of days prior to the main event in a stimulating atmosphere conducive to networking. Skillfully conceived, organized, and executed by Eneida de Paula (Campinas) and Eduardo Reis (São Paulo), this too had to be adapted to a “virtual reality.” The successful solution turned out to be a series of fortnightly thematic webinars, including a talk from a recognized authority in the field followed by three or four short presentations from the participants themselves (Table ​(Table1).1). The standard was extremely high and the YSP ended up being a highly effective warm-up to the congress itself. Furthermore, there was excellent geographical diversity among the participants with Europe, Africa, Asia, the Middle East, and both North and South America represented.Table 1Young Scientist Webinar Program

Recurrent posterior circulation infarction caused by anomalous occipital bony process in a young patient

Background

Structural anomaly of the cervical spine or craniocervical junction has been reported as one of the rare causes of ischemic stroke. We report a case of a young patient with recurrent posterior circulation infarction that may have been associated with an anomalous occipital bony process compressing the vertebral artery.

Case presentation

A 23-year-old man experienced recurrent posterior circulation infarction 5 times over a period of 5 years. He had no conventional vascular risk factors. Young age stroke work-up including thorough cardiac, intra- and extracranial vascular evaluation and laboratory tests for the hypercoagulable state or connective tissue disease yielded unremarkable results. An anomalous bony process from the occipital base compressing the left vertebral artery was observed on brain CT. All the recurrent strokes were explainable by the arterial thromboembolism originating from the compressed left vertebral artery. Therefore, the left vertebral artery compressed by the anomalous occipital bony process may have been the culprit behind the recurrent thromboembolic strokes in our patient. Intractable recurrent strokes even under optimal medical treatment led us to make a decision for the intervention. Instead of surgical removal of the anomalous occipital bony process, the left vertebral artery was occluded permanently by endovascular coiling after confirming that this would cause no neurological deficits or flow disturbance in the posterior circulation. There was no recurrence of stroke for 2 years after permanent occlusion of the left vertebral artery.

Conclusion

Arterial thromboembolism originating from the left vertebral artery compressed by the anomalous occipital bony process is a rare but not to be overlooked cause of posterior circulation infarction. When intractable to medical treatment, endovascular occlusion of the vertebral artery without flow disturbance to the posterior circulation may be a useful treatment option when surgical removal is not feasible.