Russian Polenov Neurosurgical Institute,

Saint Petersburg, Russia

 

In our country the basis for organization and realization of medical assistance is the Federal Law of Russian Federation from November, 21, 2011, #323-FZ “About the Foundations for Health Protection in Citizens of Russian Federation”. However complexity in health care system gives significant organizational difficulties for its improvement and realization of different types of specialized medical assistance.

The special problem is rendering medical assistance in neurotrauma because of its severity, significant incidence and high level of persistent work incapacity. As for polytrauma, the proportion of concomitant traumatic brain injuries is at least 70 %, and its incidence is 1-1.5 cases for 1,000 of population. The incidence of isolated TBI is at least 10-13 ‰, spinal cord injury is up to 2 ‰, peripheral nervous system injury ‒ up to 0.3 ‰ [1, 2, 3, 4, 5].

Objective ‒ to study availability of neurosurgical assistance for neurotrauma in the big city and in the region of low population density. The following tasks were developed: 1) to analyze documents regulating medical assistance; 2) to offer classification of the Russian regions according to the population density; 3) to develop a technique for evaluation of availability of specialized assistance for neurotrauma according to different population density; 4) to offer some measures for increasing availability of specialized neurosurgical assistance.                    

 

 

MATERIALS AND METHODS

The method of content analysis was used for investigation of the federal laws of Russian Federation and the orders by Ministry of Health of Russian Federation for 2000-2013 (248 observation units). On the basis of the mean population density in Russian Federation we offered the classification of the regions according to the population density. In Russia the mean population density is more than 6 times lower compared to the average world values (50.9 persons for km²). It is 8.3 persons for a square kilometer. The maximal density is registered in the Central and Southern Federal Districts, the minimal one ‒ in the Siberian and Far Eastern regions [6, 7, 8]. Therefore, the regions with low density population were considered the locations with up to 4 persons for km², with moderate density ‒ 4.1-16 persons per km², and high density ‒ more than 16.

The different systems of point estimation are widely used for standardization and estimation of information in medical practice [9, 10, 11]. The offered technique for assessing availability of specialized assistance for neurotrauma was based on separation of 6 factors, which limit assistance according to emergency: 1) remote distance from location of services, 2) state of connection for distant consultations, 3) state of roads and transport availability, 4) seasonal and daily limitations of movement, 5) availability of another consultant in case of occupation, 6) possibility for transportation of a consultant. Only two factors (state of connection for distant consultations and seasonal or daily limitations of movement) were common for the region of low density and the big city. For the region of low density the availability of another consultant and his/her transportation was not so significant. For the big city the less significant factor was great distance from location of services and state of roads. The factors of limitation of available neurosurgical assistance were found by means of the analysis of expert data after questionnaire survey for neurosurgeons in the region of low population density and in the big city (64 questionnaires). Each factor received 3-5 characteristics which were evaluated in points with increasing from the best one to the worst one, and with the following summing. The availability of specialized neurosurgical assistance was assessed with resulting sum (4 points ‒ the best value, 15 ‒ the worst one). Assistance was considered as unsatisfactory if the value exceeded 10 points, satisfactory ‒ from 9 till 6 points, and good ‒ lower than 5. The technique was tested in the region of low population density (Komi Republic) and in the big city (St. Petersburg).

 

RESULTS AND DISCUSSION

For the content analysis 4 groups of the scientific organizational clusters were separated: 1) the order of rendering medical assistance; information about patient’s logistics was considered as informative units of the analysis; 2) the norms for medical assistance and its organization with analysis informative units in view of protocols and standards of medical assistance and different standards for medical facilities; 3) the issues of treatment for countryside inhabitants; the informative units were organization and logistics of medical assistance in rural settlements; 4) the problems of availability of medical assistance; the informative units ‒ organization of available medical assistance and availability of specialized medical assistance, particularly, with dependence on population density, structure and type of settlement.

The study showed that the principles of organizing medical assistance for the population of Russia and the calculation of the standards are presented in some documents from the Government and the Health Ministry of Russian Federation (both long acting and annually renewing). Moreover, during calculations only population segment is considered without characteristics of settlement in the specific area. The documents for organization and estimation of requirements of medical assistance do not include the principle of availability which acquires special significance in the large territories with low population density. The content analysis of the documents for organization of medical assistance for the population showed that 91.5 % of these documents regulate the order of its realization. 8.5 % of the sources are dedicated to calculation of standards (mostly for rendering medical assistance). Some documents (9.5 %) include the issues of treatment for countryside inhabitants, but without consideration of specific features of settlement. 14.3 % of the examined sources included the word combination “availability of medical assistance”. Available assistance was considered as availability of specialists of medical profile for specific amount of inhabitants without consideration of structure and type of settlement, and population density. It is necessary to note that the Federal Law “About Foundations of Health Protection for Citizens in Russian Federation” does not give the definition for availability of medical assistance and its quality.

Therefore, the data of content analysis shows that the documents for regulation of medical assistance do not include enough information about its availability, particularly, in relation to settlement features.

Komi Republic is the territory of 416,774 km² in the northern-eastern part of the European part of Russia. It takes 13^th place according to the square among the regions of Russian Federation. According to our classification it relates to the territories of low population density (2.09 per km²). As for January, 1, 2014, the population of the republic was 872,057, 22.5 % ‒ in the countryside. The mean age of the population is 37.2, the mean life expectancy ‒ 68.3. The neurosurgery service was characterized with great development in Komi Republic for the last decade. It is completely located in Syktyvkar, the capital of the republic. The adult neurosurgery departments are located in Komi republic hospital and in the city hospital of Ezhvinsky district. The pediatric neurosurgery departments are located in the regional pediatric hospital. Komi Republic resuscitation consultation center, which is based on the Komi Republic hospital, takes a part in organization of consultative and travelling team neurosurgery assistance for the population of Komi. Departure and consultations are performed by a neurosurgeon of the first or the highest qualification category who is on duty at moment of call or head of department. Issues of transportation of a consultant are solved depending on transport availability in territory from which a call appears.

The technique for assessing neurosurgery assistance for neurotrauma in the region of low population density at the example of Komi Republic included estimation of the following factors limiting availability and the characteristics: remoteness from Syktyvkar (up to 50 km ‒ 1 point, 51-100 km ‒ 2, 101-200 km ‒ 3, more than 201 ‒ 4), state of telecommunications for distant consultations (fine ‒ 1 point, good ‒ 2, satisfactory ‒ 3, unsatisfactory ‒ 4), state of roads (fine ‒ 1, good ‒ 2, satisfactory ‒ 3, unsatisfactory ‒ 4), seasonal availability of movement through the territories (unlimited ‒ 1 point, moderately limited ‒ 2, significantly limited ‒ 3). On the basis of point estimation all regions of Komi Republic were grouped into 3 clusters. The greatest cluster was with unsatisfactory availability of neurosurgery assistance for the population. The districts with unsatisfactory availability of neurosurgical assistance (10-15 points) include 76.4 % of the republican subnational entity with the population of 37.7 %. The mean value of availability of neurosurgical assistance is 10.5 points.

Saint Petersburg is the major city of federal significance and the administrative center of Northwestern Federal District. The city is located in the northern-western part of Russia, on the shore of Gulf of Finland in the entry of Neva river. St. Petersburg includes 18 districts consisting of 111 municipal intracity units. The units include the municipal districts (81), towns (9) and settlements (21). According to the data from January, 1, 2014, the population is 5,131,942. The mean age of the inhabitants is 41.4, the mean life expectancy is 73.1. St. Petersburg takes the square of 1,439 km². The population density is 3,566.3 persons per km².

The following features were considered during estimation of availability of neurosurgery assistance in the big city at the example of St. Petersburg. There are the trauma centers of level I and II in the city. There is 24 hour neurosurgery service in the trauma centers of level I (6 hospitals for adults and 2 pediatric facilities). There is no such service in the trauma centers of level II (7 adult and 3 pediatric hospitals). It indicates the problem of availability of neurosurgical assistance. The trauma centers of level II are mainly located in so called satellite towns (80 %) which are the part of St. Petersburg district. Only 2 hospitals are situated in the city center. About a quarter of patients (different severity) are admitted here. According to the order by the Healthcare Committee of St. Petersburg Government, the trauma centers of level II are related to three travelling neurosurgery teams (for adults) which are based in the city center (Polenov Neurosurgery Institute, Mariinsk hospital) on the right side of Neva River (Aleksandrovsk hospital). The teams work day-and-night, with one neurosurgeon on duty. Only one of three teams has a special neurosurgeon without another job position. In this team the traveling is realized with attached medical transport. It results in approximately two time decrease in time of delivery of a consultant because of no transport waiting. In other teams a consultant needs to wait a car after a call. In other teams the position of travelling team physician is conventional: at the moment of a call a neurosurgeon may perform an operation or be at reception of patients. Instead of him /her, another physician departs and it negatively influences the availability of neurosurgical assistance.

Pediatric special medical assistance in the level II trauma centers is realized by any free neurosurgeon on duty from City Pediatric Hospital by the name of K. Rauchfus. There is no special transport for the team.

The technique for assessing availability of neurosurgical assistance in the big city is based on the range of the following factors limiting availability of specialized assistance with consideration of metropolis characteristics. The research included: 1) the state of telecommunications for distant consultations between the level II trauma center and the travelling team (fine state: the hospital can provide appropriate 24 hour connection by phone or Internet ‒ 1 point, good state: the hospital can provide appropriate connection by phone or Internet in the daytime ‒ 2 points, satisfactory state: the hospital can provide phone connection ‒ 3, unsatisfactory: the hospital cannot provide appropriate phone connection ‒ 4); 2) 24 hour availability of travelling through the city for movement to the level II trauma center and from it (unlimited ‒ 1 point, moderately limited ‒ 2, significantly limited ‒ 3); 3) a possibility for substitution of a consultant in case of busyness (constant possibility ‒ 1, generally yes ‒ 2, a possibility is not always ‒ 3, no possibility ‒ 4); 4) possibilities for transportation of a consultant (own transport and constant possibility for calling city medical transport ‒ 1, own transport and a possibility for calling city medical transport as an exceptional case ‒ 2, only own medical transport ‒ 3, only city medical transport ‒ 4). For the level II trauma centers the rate of availability of neurosurgical assistance varied from 12 till 14 points, with the mean rate of 13.5. In the city the rate of available neurosurgical assistance for neurotrauma was satisfactory. It was 8.9 points considering availability in the first level trauma centers (the highest availability).

For development of suggestions for increasing availability of specialized assistance for neurotrauma the decreasing availability factors were distributed into 3 groups: 1) the factors which are corrected by means of medical facilities and agencies, 2) the factors which are corrected by means of non-medical facilities and agencies, 3) the factors which are non corrected by means of medical facilities and agencies. Therefore, the influence for improvement is possible only for the factors of the groups 1 and 2. The measures of the group 1, which are realized by means of medical facilities and agencies, are arrangement of neurosurgeon’s duty of travelling team without his/her activity in operating room, provision of a team with own transport, setting up remote consultations using modern computer technologies, using alternative transport types (aviation, water transport). The measures of the group 2, which are recommended for non-medical facilities and agencies, include improvement of traffic arteries and building new roads to settlements and urban-type villages.

 

CONCLUSION:

1. The results of the content analysis of the documents regulating medical assistance show insufficient attention to the issues of its availability.

2. For Russian Federation, with the average population density of 8.3 per km², the regions of low population density are with the values of 4 per km², of moderate density ‒ 4.1-16 and of high density ‒ more than 16.1.

3. The developed technique showed that in Komi Republic, the region of low population density, the availability of specialized assistance for neurotrauma was unsatisfactory for the proportion of more than one third of the population (37.7 %). The availability is satisfactory in the big city (St. Petersburg).

4. The measures for increasing availability of specialized neurosurgical assistance are to be realized by both medical and non-medical facilities and agencies.