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Tsarik G.N., Korbanova T.N., Abrosova O.E., Ten S.B.
Kemerovo Institute of Socioeconomic Problems in Healthcare, Kemerovo, Russia
ASSESSMENT OF ACCESSIBILITY AND QUALITY OF MEDICAL REHABILITATION IN THE KEMEROVO REGION
The issues of organization
of measures for efficient medical rehabilitation present the priority problem
of modern Russian healthcare [1]. Arrangement of medical rehabilitation in compliance
with the modern requirements is the most important task of provision of quality
and availability of medical care, decreasing period of disability in conditions
of the three-level system of medical care realization over the long time of
increasing volume and number of types of high tech medical care, distribution
of its techniques and subsequent transition of high tech medical care to the
specialized level [2].
In USA, the most common
model of medical rehabilitation for patients with chronic obstructive lung
disease is the outpatient program on the basis of the multi-profile hospital.
Medical rehabilitation for chronic obstructive lung disease (COLD) has the
confirmed effect of improvement in the functional condition and life quality in
patients with COLD according to the conclusion from American Thoracic Society,
European Respiratory Society, Association of Cardiovascular and Pulmonary
Rehabilitation based on Evidence-Based Clinical Practice Guidelines [3]. The
study by A.L. Lo et al showed the efficiency and patients’ high satisfaction
for using the assisted robotics in the restorative period after stroke. However
some findings show the insufficient efficiency of such care at the phase of
intensive care [4]. The positive time course of the main criteria of the
maximally individualized rehabilitation programs for oncologic patients with
consideration of the process localization has been shown. Dubiley G.S., Statsenko
G.B. et al assessed the efficiency of two-week course of medical rehabilitation
of patients with oncologic diseases of different localization in the conditions
of the specialized rehabilitation department of sanatory type [5].
The analysis of activity of
the medical facilities and the specialists dealing with outpatient medical
rehabilitation shows the low availability of rehabilitation units and
specialists in Russia. In its turn, it testifies the absence of organizational
and legal forms regulating the amount of patients from active treatment to
rehabilitation, resulting in the population’s unsatisfied requirements for this
type of medical services. The constructive analysis of the situation and
identification of the unsolved problems give the foundations for development of
priority actions for advancement in outpatient medical rehabilitation, i.e. the
medical condition for realization of medical and social function of the
government in terms of preservation and promotion of health [1].
The study objective
– to assess the
quality and availability of medical rehabilitation in Kemerovo region.
For increasing the
availability and quality of medical services, the number of the medical rehabilitation
beds has increased in 2012-2017. Estimation of satisfaction and quality of
medical services was conducted in the first quarter of 2017 in the hospital and
outhospital conditions and in the health resort facilities of Kuzbass (the
stages 1-3 of medical rehabilitation). The study was carried out after
implementation of the multi-stage systematic medical rehabilitation for the
Kemerovo region population. The results were estimated with the medical and
social criteria. The population satisfaction relating to medical rehabilitation
was performed by means of development of the special questionnaires for
outpatients and inpatients, subsequent survey for the Kemerovo region
population and the information analysis.
The medical documents were
analyzed at the stages of medical rehabilitation, with the aim of estimating
the medical rehabilitation quality and achievement of medical efficiency of
medical services in the facilities.
MATERIALS AND METHODS
The social hygienic study
was conducted with the following methods: historical, sanitary statistical,
monographic, economic-mathematical, systemic approach and analysis, direct
observation, modelling, expert estimation and graphic pictures. The medical documentation
was examined, and surveying the patients at the various stages of medical
rehabilitation was performed that allowed estimating the availability of
medical rehabilitation in the population satisfaction in Kemerovo region.
The research subject was the
population of Kemerovo region. The observation unit was each resident. The
research subject of medical provision included 13 medical facilities rendering
the medical rehabilitation services in outpatient and inpatient conditions. The
organization of the study involved the gradual realization of the stages:
making the plan, data collection, preparation and summarizing of materials,
data analysis and efficiency estimation.
The prospective study of
public health and medical care arrangement was conducted. The study included
the population of Kemerovo region with cardiovascular and neurologic diseases
and injuries.
The patients’ satisfaction
in relation to medical rehabilitation was estimated by means of survey. The
number of the persons with improving (or worsening) health after inpatient or
outpatient treatment was considered for estimating the medical efficiency of
the medical rehabilitation process.
The time course of work
incapability days and the mean duration of a single case of work incapability
were estimated.
Statistical analysis methods
The study included the residents of Kemerovo region with cardiovascular and neurologic diseases and trauma patients. The statistical analysis was carried out with Microsoft Office 2013 Pro Ru for electronic tables (Open License 62007606). IBM SPSS Statistics Base Campus Edition Campus Value Unit License v. 24 (the license agreement No. 20160805-1, August 30, 2016, CJSC Predictive Solutions) was used for testing statistical significance of the results.
RESULTS
290 medical records were investigated. The patients received the medical care in the inpatient and outpatient conditions (the stages 1-3 of medical rehabilitation) of the medical facilities of Kemerovo region (Leninsk-Kuznetsky, Kemerovo, Novokuznetsk, Prokopyevsk). 55 medical records were estimated (15 medical records of the outpatients (the account form No.025/u) of the polyclinic and 40 medical records of the inpatients treated in the cardiology and rehabilitation units (the account form No.003/u)) of Barbarash Regional Clinical Cardiologic Dispensary; 22 medical records of the inpatients (the account form No.003/u) of the cardiologic dispensary and 50 medical records of the neurologic unit inpatients in Prokopyevsk Clinical Orthopedic and Surgical Hospital of Remedial Treatment; 50 medical records of the inpatients (the account form No.003), Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky; 20 medical records of the inpatients (the account form No.003/u) and 30 medical records of the patients receiving the outpatient medical care (the account form No.025/u), Kemerovo City Clinical Hospital No.1 named after M.N. Gorbunova. The expert estimation was conducted for 11 medical records of the outpatients in the Polyclinic No.1, 21 medical records (the account form No.025/u) in the Polyclinic No.2 (including 8 medical records of the day patient department of the polyclinic, home care and the day patient department of the hospital (the account form No.003-2/u-88) and 20 medical records (including 7 medical records with the account form No.003-2/u-88) in the polyclinic No.4, Novokuznetsk City Clinical Hospital No.29, the account form No.025/u (Fig. 1).
Figure 1. The structure of conducted expertise of medical
documentation
All patients showed the
rehabilitation potential. The first stage of medical rehabilitation was initiated
in appropriate time. The patients were reasonably directed to the stages 2-3. Inhalation
treatment for decreasing chronic inflammatory processes and early physical
rehabilitation with the appropriate mode, with use of cardio- and
neurorehabilitation and medical rehabilitation for locomotor system diseases, are
used in Regional Clinical Center of Miners’ Health Protection, Prokopyevsk Regional
Clinical Orthopedic and Surgical Hospital of Remedial Treatment, Novokuznetsk
City Clinical Hospital No.1, Barbarash Regional Clinical Cardiologic
Dispensary. After initiation of intensive care, the treatment process includes
the physiotherapist: the procedures for prevention of bedsores, thrombosis and
chronic pulmonary events (ultraviolet irradiation for regions of shoulder
bones, buttocks and heels); intermittent pneumocompression for the lower
extremities (after lower extremity vessels DS for diagnosing the floating
clots). The medical documentation reflects the recurrent consultations from therapeutic
exercise specialists and physiotherapist with recommendations for discharge. The
neurologic scales are used. The changes in medical records and discharge
letters are indicated. It simplifies the work of rehabilitation specialists at
the second stage of medical rehabilitation. 193 medical records of the
inpatients included the staged discharge letters with estimation of changes in
the patient’s condition and correction of treatment. The multidisciplinary
team’s round was designated in 100 % of the medical documents. The recurrent
protocol of the multidisciplinary team session was carried out with designation
of the time course according to Rankin score in 86 % of the cases (167 units of
medical documentation, the account form No.003/u). The outpatient service:
within the limits of the stage 3 of medical rehabilitation, the outpatient
medical records (the account form No.025/u) and the day inhospital records (the
account form No.003-2/u-88) were examined in the Polyclinics 1, 2 and 4 of
Novokuznetsk City Clinical Hospital No.29, in the Polyclinic No.3 of Kemerovo
City Clinical Hospital No.1 named after M.N. Gorbunova. Some medical records (6
records, the account forms No.003-2/u-88 and No.025/u, 6.2 % of the cases) did
not include the consultation from remedial gymnastics specialist and physiotherapists.
Summarizing the
questionnaire results for the period of February-March 2017, one should note
that 834 persons were surveyed: 347 men (41.6 %) and 487 women (58.4 %) (Fig.
2).
Figure 2. The structure of patients participating in questionnaire
All patients were at the
medical rehabilitation stage in the medical facilities of Kemerovo region in
the cities: Anzhero-Sudzhensk, Kemerovo, Novokuznetsk, Leninsk-Kuznetsky and in
the municipal regions of Prokopyevsk, Yurga and Yashkino. The study was
conducted in the outpatient and inpatient (the stage 2 of medical
rehabilitation) conditions, and in the health resort facilities (the stage 3 of
medical rehabilitation). The study included the rehabilitation units of
cardiology, neurology, traumatology and pulmonology profile.
The questionnaire for the
patient of the medical rehabilitation polyclinic included 8 items, the
questionnaire of the inpatient – 6. At least 5 variants of answer should be
chosen: “satisfied”, “rather satisfied than unsatisfied”, “partially
satisfied”, “I do not know”, “not satisfied”. The answers “satisfied” and
“rather satisfied than unsatisfied” were summed subsequently, as well as the
negative responses relating to dissatisfaction of the respondents.
The social status of the
patients and their age and gender distribution were considered. Most patients were
persons at the age of 46-60 (304 persons, 36.5 %). The second place was taken
by persons at the age of 60 and older (191 persons, 34.9 %), the third place –
persons at the age of 36-45 (114 patients, 13.6 %), followed by 7.3 % of
persons at the age of 26-35 (61 persons), the age of 18-25 – 49 persons (5.8 %)
and persons at the age < 18 (students of high schools, colleges and
universities) – 15 persons (1.8 %) (Fig. 3).
Figure 3. Age distribution of patients participating in
questionnaire at the outpatient and hospital stages of medical rehabilitation
50.4 % of the patients were
presented by employed persons, and 49.6 % – by unemployed persons. 227 respondents
were questioned in the polyclinic: 104 men (45.8 %) and 123 women (54.2 %). The
outpatient study was conducted on the basis of the pulmonology department of
Kemerovo City Clinical Polyclinic No.5, Kemerovo City Clinical Hospital No.1
named after M.N. Gorbunova, Regional Clinical Center of Miners’ Health
Protection (Leninsk-Kuznetsky), Kemerovo Clinical Cardiological Dispensary (the
cardiologic polyclinic), Novokuznetsk City Clinical Hospital No.1, Yurga City
Hospital and Yashkino Regional Hospital. The polyclinic patients were 27.2 %,
the patients of the inhospital medical rehabilitation units – 72.8 % among all
questioned patients.
The patients of outpatient
medical rehabilitation had the following age distribution: 1st place – the age
of 46-60 (61 persons, 26.8 %), 2nd place – the age of 36-45 (46 patients, 20.3
%), 3rd place – the age of 60 and older (44 patients, 19.4 %), followed by the
age of 26-35 (39 patients, 17.2 %), the age of 18-25 (25 patients, 11 %), the age
< 18 (15 patients, 6.6 %). The employed persons prevailed among all
outpatients receiving medical rehabilitation (50.4 %). There were 49.6 % of
unemployed persons (including temporally unemployed, decree leave, child-care
leave). The retired persons were 23.9 %, the disabled – 8.8 % including the
group 1 – 10 %, the group 2 – 60 %, the group 3 – 30 %.
186 patients (110 women, 76
men, 81.9 %) were satisfied with the timeliness of referral to medical
rehabilitation, 9.7 % (22 patients, 12 women and 10 men) were rather satisfied
than unsatisfied, uncomplete satisfaction – 3.9 % (9 patients, 4 women and 5
men). 3.5 % of the patients selected the point “I do not know” (7 women and 1
man), 3 patients were unsatisfied (2 men and 1 woman, 1.3 %). Therefore, 91.6 %
of the respondents were satisfied with timeliness of referral to medical
rehabilitation, 8.4 % - unsatisfied. 82.4 % of the patients (187 persons) were
satisfied regarding the doctors’ behavior (surgeon, neurologist,
ophthalmologist, cardiologist, physiotherapist and others), 17 patients (7.5 %)
were rather satisfied resulting in the total of 89.9 % of the respondents. 10.1
% of the patients (17 men and 3 women, 8.8 %) were unsatisfied with the
doctors’ behavior, 1 woman selected “I do not know” (0.4 %), 2 men were
unsatisfied (0.9 %). The activity of the auxiliary services (the procedure room,
laboratory and others) was satisfactory for 197 respondents (86.8 %). 19
patients (8.3 %) were rather satisfied than unsatisfied, resulting in the total
of 95.1 % of the respondents. 4.9 % of the respondents were unsatisfied (6
patients, 2.6 %) were partially satisfied), 1 woman (0.5 %) answered “I do not
know”, 3 men and 1 woman were unsatisfied (1.8 %). The
nursing
staff
services
were
satisfied
for
208 respondents
(91.7 %). 14 respondents
(6.1 %) were rather satisfied than unsatisfied, resulting in the total of 97.8
% of the respondents. The nursing staff services were unsatisfied for 2.2 % of
the respondents (2 men and 2 women (1.7 %) were partially satisfied), 1 man was
unsatisfied (0.5 %). 191 persons (84.1 %) were satisfied with the results of
the medical rehabilitation, 28 respondents (12.3 %) were rather satisfied than
unsatisfied, resulting in the total of 96.4 % of the respondents. The medical
rehabilitation results were unsatisfied for 3.6 % of the respondents (1 woman, 0.5
%) was rather satisfied than unsatisfied. 5 respondents (2.2 %) answered “I do not
know”. 2 men were unsatisfied (0.9 %).
The dissatisfaction was
estimated according to the various criteria. The patients could select several
answers (from 1 to 7) including long waiting for medical rehabilitation and
consultations or absence of physicians; denial for referral to consulting,
examining and physical treating by other specialists; denied referral to
admission or long term waiting for planned admission to hospital or day
hospital for medical rehabilitation; denied referral to other specialists,
examination and physiotherapy; rudeness
and inattention of medical staff; reporting the health state findings to other
persons without patient’s consent; absent awareness of a disease, possible
complications and treatment techniques.
The results of the
questionnaire showed the following causes of dissatisfaction: long waiting for
medical rehabilitation – 8.8 % (20 persons), long waiting for consulting or
absent specialists (19 respondents, 8.4 %), denial for referral to admission or
long waiting for planned admission to hospital or day time hospital for medical
rehabilitation (6 respondents, 2.6 %), denial for referral to consulting from
other specialists, to examination or physiotherapy (5 respondents, 2.2 %),
unawareness regarding disease, possible complications or treatment techniques
(6 respondents, 2.6 %), medical staff rudeness or inattention (2 respondents,
0.9 %). The figure 4 shows the dissatisfaction causes.
Figure 4. The structure of causes of dissatisfaction of
respondents in relation to medical rehabilitation services in outpatient
conditions
The satisfaction relating to
material and technical resources (presence of diagnostic equipment, laboratory
diagnostics and others) was 78.4 % (178 persons). 37 respondents (16.3 %) were
rather satisfied than unsatisfied, resulting in the total of 94.7 % of the
positive responses. 5.3 % of the respondents were unsatisfied with material and
technical resources (7 respondents (3.1 %) were partially satisfied, 3
respondents (1.3 %) selected “I do not know”, 2 women were unsatisfied (0.9
%)).
182 respondents (80.2 %) did
not pay for outpatient medical rehabilitation. 12 patients (5 women and 7 men) paid
for it (5.3 %). 6 women paid for the treatment (2.6 %), including 1 woman who
paid the services according to her own will. 3 patients paid for the medical
consultations (1.3 %). 18 patients (7.9 %) paid the services in other medical
facilities. 3 patients (1.3 %) paid for the pharmaceuticals and other medical
supplies (syringes, gloves, systems) in the day time hospital. 189 patients
(83.2 %) were satisfied with the polyclinic services, 22 patients (9.7 %) were
rather satisfied than unsatisfied, resulting in the total of 92.9 % of the
respondents. 7.1 % of the respondents were unsatisfied with the polyclinic
services (14 patients (6.2 %) were partially satisfied, including 8 men and 6 women;
2 women (0.9 %) selected “I do not know”).
The estimation of the
patient’s satisfaction at the inpatient stage of the medical rehabilitation was
conducted on the basis of the units in the medical facilities: the neurosurgery
units No.1 and 2, the therapy units No.1 and 2, the neurology unit of Regional
Clinical Center of Miners’ Health Protection (Leninsk-Kuznetsky), the
cardiology, neurology and therapy units of Novokuznetsk City Clinical Hospital
No.2, the cardiology unit of Kemerovo Clinical Cardiologic Dispensary, the
neurology and traumatology units of the Medical Rehabilitation Center of
Kemerovo City Clinical Hospital No.1 named after M.N. Gorbunova, the neurology
unit of Anzhero-Sudzhensk City Hospital, the cardiology units No.1 and 2, the
neurology unit for patients with acute cerebrovascular accident and No.2, the
traumatology and orthopedics units No.1, 2, 3, the burn treatment unit of Novokuznetsk
City Clinical Hospital No.1, the neurology, traumatology and cardiology units
of Yurga City Hospital, the therapy unit of Yashkino Regional Hospital, the
neurology cardiology units of Prokopyevskiy Sanatorium and Mercury Sanatorium
(Kemerovo). The inpatient questionnaire for estimating the availability and
quality of the medical rehabilitation was offered to 607 patients (243 men
(40.1 %) and 364 women (59.9 %)). The inpatients were 72.8 % among the total
amount of the respondents at the outpatient and inpatient stage (Fig. 5).
Figure 5. Distribution of respondents in relation to medical
rehabilitation services in outpatient and hospital conditions
The highest amount of the respondents were at the age > 60 (255 persons, 42 %), the second place was taken by the persons at the age of 46-60 (217 persons, 35.6 %), the third place – the age of 36-45 (57 persons, 9.4 %), followed by the age of 26-35 (55 persons, 9.1 %), 18-25 (22 persons, 3.6 %) and less than 18 (1 person, 0.2 %) (Fig. 6).
Figure 6. The structure of respondents in relation to medical
rehabilitation services in hospital conditions
The employed persons
prevailed among the patients of the specialized stage of the medical
rehabilitation (185 persons, 30.5 %) including 85 employed retirees (14 %). The
total ratio of the employed persons was 44.5 %. The unemployed patients were
55.5 % (including 1.8 % of temporarily unemployed, decree leave and child care
leave). The retired persons were 36.5 %, disabled persons – 6.9 % including the
group 1 – 1.5 %, the group 2 – 3.7 % and the group 3 – 7 %.
506 patients (83.4 %) were
satisfied with the physicians’ attitude, 21 (3.5 %) – rather satisfied than
unsatisfied, resulting in the total of 86.9 % of the satisfied persons. 13.1
% of
the
patients
were
unsatisfied.
565 patients (93.1 %) were
satisfied with the nursing staff attitude, 32 (5.2 %) – rather satisfied than
unsatisfied, resulting in the total of 98.3 %. 1.7 % of the respondents were unsatisfied
(10 persons – partially satisfied). 79.6 % of the respondents (483 patients)
were satisfied with the auxiliary services (laboratory, the procedure room,
physical therapy room and others), with 42 respondents (6.9 %) of rather
satisfied than unsatisfied, resulting in the total of 86.5 % of the satisfied
patients and 13.5 % of partially satisfied. 498 respondents (82.1 %) were
satisfied with the nursing staff services, 33 respondents (5.4 %) – rather
satisfied than unsatisfied, resulting in the total of 87.5 % of the satisfied
persons. 12.5 % of the respondents selected “I do not know”. 86.8 % of the respondents were satisfied with the medical
services (470 respondents were satisfied (77.4 %), 9.4 % (57 respondents) –
rather satisfied than unsatisfied). 13.2 % were unsatisfied.
The dissatisfaction with the
medical services was conditioned by insufficient provision of medical agents (6
respondents), sanitary conditions in a medical facility (11 respondents),
medical staff rudeness and inattention (1 respondent). Long waiting or denial
for medical consultations, examination and physical therapy were the causes of
dissatisfaction in 3 respondents, nutrition quality – 7 respondents. Satisfaction
was higher for the inhospital stage of rehabilitation than for outpatient
rehabilitation (Fig. 7). Satisfaction with the sanatory stage of the medical
rehabilitation was about 100 %.
Satisfaction of
respondents in relation to medical rehabilitation services in outpatient and
hospital conditions
The rate of payment for inhospital services of the medical rehabilitation was 9.1 % (55 persons). 90.9 % of the patients paid the services with their own money. 55 patients paid for the examination: medical consultations (5 patients), prescribed medical agents (7 patients), payment for medical services in other medical facilities (46 patients).
CONCLUSION
1. The increase in quality
and availability of the medical rehabilitation was promoted by controlling the
quality of medical services by means of improving material and technical
resources of the medical facilities and adherence to the order of rendering
medical rehabilitation. With the aim of realization of medical rehabilitation
technologies, the availability of the specialized medical beds increased from
0.023 (0.022-0.024) bed days per one resident in 2009-2011 to 0.039
(0.038-0.0040) in 2012-2016 (p = 0.001), i.e. 1.7-fold increase.
2. The examination included
290 medical documents of the patients treated in the medical facilities of
Kemerovo region. All patients were appropriately selected for all stages of the
medical rehabilitation and had the rehabilitation potential. The functioning
values were examined again after completion of the medical rehabilitation. The
number of the patients with improving health condition after the inhospital
treatment at the stage 1 of the medical rehabilitation increased from 95.1 %
(94.6-95.6) in 2009-2011 to 97.0 % (96.5-97.5) in 2012-2016 (p = 0.0001). It
testified the medical efficiency of the rehabilitation process.
3. The satisfaction with the
outpatient medical rehabilitation quality achieves 82.2 %, inpatient
rehabilitation – 85.8 %, in health resort conditions – about 100 % (98.8 %).
The number of work incapability decreased from 683.1 (665.1-694.3) in 2009-2011
– 519.9 (482.3-589.0) per 100 employed persons in 2012-2016 (p = 0.0001). The
above-mentioned values testified the social efficiency of the techniques for
arrangement of restorative treatment.
Information about financing and conflict of interests:
The study was conducted without sponsorship.
The
authors declare the absence of clear and potential conflicts of interests
relating to the publication of this article.
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