Просмотров: 3 193
Khanov А.G. Key words: rheumatic diseases, rheumatologic in-patient clinic, in-patient treatment of rheumatic diseases, admission rate structure for rheumatic diseases, duration of in-patient treatment of rheumatic diseases, assessment of the in-patient clinic rheumatologist’s work, criteria of the rheumatologist’s individual professionalism, medical rating, efficiency of the rheumatologic service’s work. Relevancy. Health care aims at maintaining and strengthening the people’s health. For realization of these tasks it is important to efficiently use the field’s resources. The existing indicators of healthcare institutions’ performance are significant, but they don’t reflect the essence of the doctor’s work as a healer. These indicators are more suitable for accounting or financial revision purposes. It is essential not only to include available beds and supercomplex expensive equipment, but also to flesh out the treatment and diagnostic process with the shortest path to the exact diagnosis. The efficiency of work of any medical service is determined with organization of joint work of the outpatient and in-patient clinical units. The “heart” of this system is medical staff and, especially, its doctors. There are no objective criteria for assessment of the doctor’s personal skills and his/her contribution to the department’s work, especially in the context of multi-profile thousand-bed hospitals. Various certificates, categories, academic ranks point at the ability of the medical worker to acquire a certain volume of knowledge and skills, but do not reflect the doctor’s ability to realize them with the maximum benefit for the patient and the material profit of the medical institution. The medical rating is necessary for results of performance of a hospital, a clinic, a department and a concrete doctor. Continuity shall be observed in the work of the out-patient hospital and the in-patient clinic in the course of mutual exchange of information about the diagnosed and treated patients and operative statistic support. The results of the medical rating can be used for a complex assessment of the medical staff’s contribution to strengthening of the people’s staff, effective use of the equipment and material resources and financial motivation of employees. Purpose. On the example of performance rating of the rheumatologic in-patient clinic’s doctor for the period of three years to assess medical load, treatment results, patient population, having diagnostic and treatment opportunities of the in-patient clinic, efficiency of their use. Materials and methods. 889 medical records of rheumatologic patients treated in the rheumatologic department of the regional hospital in 2008-2010. Results and performance ratings of the in-patient clinic’s physician are given in the form of tables, diagrams and pictures. Results/Discussion. The rheumatologic department of the regional clinical hospital have stable, permanently increasing main performance indicators (table 1). Table 1 Comments. The number of treated patients is calculated as a half of the sum of admitted, discharged and dead patients (usually for the present calendar year). This indicator is obligatory for calculation of the “bed turnover”. The “bed turnover” indicator shows the average amount of patients treated in every hospital bed during the year. This indicator is arrived as a quotient of the treated patients by the number of annual average beds. In 2008 I treated 251 patients, in 2009 – 318, in 2010 – 320. The monthly medical load for 3 years is shown on the Pic. 1-3. Pic. 1 Monthly average load in 200 Pic. 2 Monthly medical load in 2009 Pic. 3 Monthly medical load in 2010 The average number of patients treated monthly in 2008 is 21, in 2009 – 26,5; in 2010 – 26,6 (see Pic. 4,5). Pic 4 Average monthly number of treated patients in years Pic. 5 Comparative monthly medical load for 3 years Maximum medical load in 2008 was registered in November (38 patients). In 2009 the “intense” work month was April (36). In 2010 in October the maximum monthly load was registered (45 patients). Profiled hospitalization in the department of rheumatologic patients is increased each year (Pic. 6-8). Comments. Specialized medical aid is a form of medical aid provided by doctors – specialists that got special training in the corresponding medical field in the appropriate medical institutions and departments to the patients with a certain pathology. Only certain-type diseases are profile for this department. Pic. 6 Distribution of treated patients in 2008 into classes of diseases Pic. 7 Distribution of treated patients in 2009 into classes of diseases Pic. 8 Distribution of treated patients in 2010 into classes of diseases The percentage of hospitalized rheumatologic patients for 3 years increased from 90% to 97%. The small percentage of the cardiologic profile patients is associated with the use of ICD codes of the circulatory diseases in cases of congenital heart disorders and rheumatic heart diseases. Also sometimes cardiologic patients with urgent conditions are hospitalized in compliance with the hospital’s medical needs. The analysis of the hospitalized patients groups is based on the data for 2008 and 2009. The percentage of hospitalized “rural” patients is very important for the regional hospital. In 2008 the percentage of Rostov region patients was 49% (Pic. 9). Pic.9 Distribution of patients treated in 2008 into groups based on place of residence and sex In 2009 42% of rural patients were hospitalized (Pic. 10) Pic.10 Distribution of patients treated in 2009 into groups based on place of residence and sex The percentage of hospitalized patients of Rostov-on-Don is high. This fact is associated with high demand in rheumatologic aid as a whole, absence of the city rheumatologic in-patient clinic and availability of the medical institution. The hospital’s administration provides facilities for attraction of patients from other RF regions and “international” patients. So far, these are citizens of the former Soviet republics. In accordance with the data of 2008 10 non-residents of RR were hospitalized, that comprises 4% of the total number of patients. Rheumatologic diseases (RHD) are widespread mostly among women. Based on the data of the 2-years examinations the percentage rate of M and W despite the different total number of treated patients remains unchanged. Women comprise 72%, men – 28%. The analysis of groups of in-patient clinic rheumatologic patients distributed into classes by sex and age is shown at the pic. 11-13. Pic.11 Distribution of patients treated in 2008 into groups based on sex and age Pic.12 Distribution of patients treated in 2009 into groups based on sex and age Pic.13 Distribution of patients treated in 2010 into groups based on sex and age In general, it is a fair consumption to say that the percentage rate of the hospitalized patients remains practically stable over a period of 3 years. The age of the half of patients is 40-60 years. Besides, approximately 70% of them are women. 25% include the age categories of 20-40 and 40-60 years. In these age groups women also comprise about 70%. The patients of the young and old age comprise 1-2% of the total number of patients in different years of examination. They are predominately women. The analysis of labor activity of hospitalized patients of working age without the disability status was conducted on the basis of the data of 2008. Thus, 44 M and 81 W of working age were hospitalized. Only 28 M and 49 W of them were involved in various production industries. The results of the analysis show that 40% (32 women) W and 27% (16 men) M of working age have no full social protection in case of rheumatic diseases mostly characterized with the progressive course. The structure of hospitalization rate of patients with RHD to the rheumatologic department of the regional hospital is shown on the pic. 14-16. Pic.14 The structure of rheumatic diseases among the patients treated in 2008 with regard to their sex Pic. 15 The structure of rheumatic diseases among the patients treated in 2009 with regard to their sex Pic. 16 The structure of rheumatic diseases of in-patient clinic patients treated in 2010 with regard to their sex The results of three years of monitoring show that the rheumatologist in the in-patient clinic frequently has to deal with 5 nosological entities: RA (36; 26,5; 28%), GOA (16; 17; 15%), reactive arthritis (9; 11; 9%), SLE (8; 6,6; 4%) and seronegative spondyloarthritis(SSA) (6; 11,5; 8%). All patients with SLE are women. 75-60% of patients with SSA are women. Among the frequently observed RDs in the in-patient clinic “men” diseases are: goutte (92; 83; 90%), AS (100; 93; 70%) and relatively GOA due to the little percentage in the structure of patients of this group ( 40; 30; 25%). The frequency of RHDs based on the admission rate is shown on the pictures in absolute figures and percentage. Thus, in 2008 patients with RA + GOA comprised 121 with the total number of patients 227 (pic. 17). Pic. 17 Frequency of nosological entities of rheumatic diseases among the patients treated in 2008 in absolute figures The frequency of RDs based on the admission rate is shown on the picture 18 in percentage. Pic. 18 Frequency of nosological entities of rheumatic diseases among the patients treated in 2008 in % The data is presented with the accrued method: RA+ GOA=53%; RA+ GOA + ReA =62%; RA+ GOA + ReA+ SLE =70%, etc. 8 nosological entities are patient groups including 1-2 patients with diagnosis of PM/ DM, EN, paraneoplastic disease, arthritis associated with connatal microspherocytic anemia, SS, Reiter’s syndrome, secondary arthropathia, CSS. Despite the little number of patients with these diagnoses that shows the level of diagnostics of the rheumatologic department of the RCH No 2. 9 patients with the specified nosological entities comprise 4,5%. In 2009 patients with RA+ GOA+ SSA comprised 161 with the total number of the group 294 (pic. 19). Pic. 19 Frequency of nosological entities of rheumatic diseases among the patients treated in 2009 in absolute figures In percentage terms it comprises 55% (Pic. 20). Pic. 20 Frequency of nosological entities of rheumatic diseases among the patients treated in 2009 in % 9 nosological entities are represented with vasculitis, PM/ DM, EN, paraneoplastic disease, combined disease (RA+ endocarditis infectious, periodical disease, Reiter’s syndrome, secondary arthro- and myopathy. This group in percentage comprises 3,8. In 2010 patients with RA+ GOAAS comprised 170 with the total number of the group 311 (pic. 21). Pic. 21 Frequency of nosological entities of rheumatic diseases among the patients treated in 2010 in absolute figures The group of 9 nosological entities with 1-2 patients also included vasculitis, PM/ DM, SS, EN, Reiter’s syndrome, paraneoplastic disease. “New” diagnoses were added: combined connective tissue disease, diabetic arthropathy, simple necrosis. In percentage this group comprises 6% (pic. 22). Cumulative percentage of RA+ GOA+ AS is 52% (pic. 22). Pic. 22 Frequency of nosological entities of rheumatic diseases among the patients treated in 2010 in % Average duration of treatment for every treated patients is shown on the basis of the results of work in 2009, on the example of 294 patients (see pic. 23), separately for M and W. The average duration of treatment for 5 frequently observed diseases is: RA -17,4 b/d; GOA -15,6 b/d; ReA – 16,8 b/d; SLE – 18 b/d. Among other frequently observed with women diseases the largest duration has treatment of AS (20 b/d), and the shortest – PsA (15,3 b/d). Among other nosological entities with the number of patients in the group 1-2 the data of treatment of paraneoplastic disease (20 b/d), periodical disease (19 b/d) and EN (17,2 b/d) is of special interest. In the first two cases the main time of treatment is spent on establishing the diagnosis. With EN not less than 17-18 b/d are needed for achievement of the clinical result. Pic. 23 Average duration of treatment of rheumatologic patients with different nosological entities in 2009 with regard to their sex Conclusion. The analysis of the scope of work of the rheumatologist in the in-patient clinic allows: – to use the objective criteria of assessment of the personal contribution of the doctor, also for financial stimulation upon the results of work; -to specify and constantly improve selection criteria of patients for hospitalization in the regional rheumatologic in-patient clinic; – to plan the need of the adult population of the territory in rheumatologic aid; – to develop voluntary health insurance; – to improve quality of diagnostics and treatment; – to plan development of the material and technical base of the department; – to conduct pharmacoeconomic calculations in the framework of compulsory medical insurance; – to plan new types of medical aid and initial expenses associated with their implementation; – to develop intrahospital standards of diagnostics and treatment of rheumatologic diseases; – to compare indicators of work data of in-patient clinic doctors of different levels and from different territories.