ORGANIZATIONAL TECHNOLOGIES OF MEDICAL REHABILITATION IN TRAUMATOLOGY
Kemerovo Institute of Socioeconomic Problems in Healthcare,
Kemerovo, Russia
Medical support for the population is determined by its health [1].
The significance of the health problems in the working population is testified by the fact of purposiveness of some normative legal acts for supporting the organizational and economical foundations of medical aid for the working population of the Russian Federation [2-4]. The federal law determines obligatory social insurance for industrial accidents and occupational diseases with payment for medical, social and professional rehabilitation upon incurrence of an insurance event [5-8]. Timeless treatment of patients with occupational pathology leads to worsening the outcomes of recovery [9].
The patients who survived critical states in intensive care units require medical rehabilitation beginning from the stage of intensive care. The efficiency of early intervention with participation of the interdisciplinary team (even for patients with ALV) and optimizing physical activity was confirmed even despite of severity of condition. The proven moments include improving health indices at the moment of hospital discharge and decrease in hospital stay [10].
The direct relationship was found between timeliness of appearance of measures for medical rehabilitation and restoration of working capability. The planned reiteration of courses with realization of the individual program of restorative treatment allowed achievement of restitution of working capability in 77.3 % of the patients [11, 12].
In 2011 WHO and the World Bank prepared the first World Report on Disability. The report presents the volume of the rehabilitation services available in the world and the range of the services in the countries with low and middle incomes, where such services exist [13].
It is necessary to consider a possibility of positive time course of disability and actualization of the issues of development and realization of efficient organizational approaches with maximal use of the accumulated potential [11].
The objective of the study was improving the efficiency of medical rehabilitation on the basis of innovative technologies for organization of medical maintenance for the population by means of increasing amount of beds in departments of medical rehabilitation of traumatology profile and improvement in quality of rendering medical aid.
For increasing the availability and quality of medical maintenance the number of beds for medical rehabilitation of traumatological profile was increased. The assistance was realized in a staged and system manner in hospital and outpatient conditions. The study was conducted before implementation of multi-staged systematic medical rehabilitation (2009-2011) and after testing the implemented organizational techniques (2012-2014). The results were estimated with use of medical, social and economic criteria.
MATERIALS AND METHODS
The study was conducted with use of the classical approach for development of the working hypothesis, the objective and the tasks. The working hypothesis supposed the improvement in medical rehabilitation on the basis of development of innovative techniques of its arrangement.
The subject of the study was the population of Kemerovo region with diseases of the musculoskeletal system and connective tissue (the group XIII including M00-M99, the code of ICD-10); the observation unit is each resident with the above mentioned pathologies. The subject of research of medical provision for the population included 35 medical facilities providing outpatient traumatological assistance, and 30 facilities providing inhospital aid. There were 8 beds for specific medical rehabilitation for traumatological patients.
The arrangement of the study provided the subsequent realization of the following stages: generation of the plan and the program, collection of the data, preparation and combination of the materials, data analysis, development and implementation of guidelines, estimation of efficiency. The choice of the study methods was based on the domestic and foreign experience in social and hygienic studies.
The retrospective clinical study was focused on public health and arrangement of medical aid of traumatological profile. Two observation periods were emphasized: before implementation of efficient technologies of medical rehabilitation (2009-2011) and after it (2012-2014).
The study included the population of Kemerovo region with the diseases of traumatological profile. The results of medical rehabilitation were estimated with the criteria for medical, social and economic efficiency.
The amount of medical rehabilitation beds and the percentage of the patients who received medical rehabilitation in conditions of medical facilities were estimated.
The amount of patients with improvement or worsening of health after hospital and outpatient treatment was considered for proving the medical efficiency of the process of medical rehabilitation.
The amount of doctors and nurses of traumatological profile per 10,000 persons, the ratio of dual jobholding, the proportion of certified and authorized specialists and questionnaire for patients in hospital and ambulatory conditions were estimated for assessment of the quality of arranged medical treatment.
The vales of incidence, mortality and its time course among the working age population, and also primary disability were estimated. The estimation included the time course of days with lost working capability, the mean duration of one case of lost work capacity in the compared periods before and after implementation of social efficiency of organizational techniques of medical rehabilitation.
The methods of statistical analysis
The study included each resident of Kemerovo region with the diseases of the musculoskeletal system.
The reliability of the results of the study was confirmed by the adequate statistical methods with use of the modern licensed statistical software MS Win 8.1 / MS Office 2013 Pro Ru (the license agreement No.620131510) and IBM SPSS Statistics 22. Pearson’s test was used for the analysis of contingency tables. The critical level of significance was p = 0.05. If this value was exceeded, the null hypothesis was accepted (absence of differences in the compared groups).
RESULTS
In Kuzbass the injury rate exceeds the average Russian value by 36 % and by 29 % in the Siberian federal district. The mortality from the external causes among the working population shows 72.9 % exceeding the values in Russian and the Siberian federal district.
The proportion of injuries in the adult population is 81 %, in the youngsters and the children – 19 %. As compared with the year 2012, the injury rate shows a trend to decrease in all age groups. Within the last 3 years the posttraumatic mortality is 0.87 % with the trend to decrease.
One of the main places in need for restorative treatment in hospital conditions is taken by injuries, poisoning and some other consequences of the external causes. Medical rehabilitation is 5,721.9 persons per 100,000.
The demand for medical rehabilitation was estimated with the differentiated regulations in reliance on 100,000 persons. The duration of restorative treatment of traumatology profile is 18.5 days. A bed is used for 18.7 days, with the annual use of a bed for 345.3 days.
Along with high demand for restorative treatment for cardiovascular and pulmonary diseases, the highest amount of bed-days is associated with injuries, poisoning and some other consequences of the external causes – 105,855.1 in the medical facilities and 110,569.2 bed-days in the health resort.
Outpatient traumatological assistance is realized by 35 regional medical facilities, inpatient assistance – by 30 (the stage 1) facilities including multi-profile traumatological aid (Regional Clinical Orthopedic and Surgical Rehabilitation Hospital, Prokopyevsk; Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky; Novokuznetsk Scientific and Practical Center of Medicosocial Expertise and Rehabilitation for Disabled Persons, Novokuznetsk).
In most departments (about 70 %) the material resources include the sufficient amount of domestic tools and expendable materials for osteosynthesis. Deterioration of the main equipment is about 50 % at average.
There are some measures for improvement in medical assistance for accidents, poisoning and injuries. The intensive care and toxicological services have been improved, and the new medical equipment has been implemented. The burn center at the basis of Kemerovo City Clinical Hospital No.3 complies with the modern requirements. The material and technical resources have been improved in most traumatology units. The training centers for training and educating the persons dealing with elimination of consequences of road traffic accidents and realizing medical treatment have been developed. The emergency car fleet has been renewed by 90 %. As for daily basis, the roads are supported by workforce and means of the emergency aid services. The responsibility fields of medical facilities in the regions near the federal road have been determined.
During the first (2009-2011) and the second (2012-2014) periods of the follow-up the leading causes of mortality were hematologic diseases, injuries, poisoning and tumors.
The realization of the medical rehabilitation techniques has provided the increase in the coverage of the special beds of trauma profile from 0.0063 (0.0062-0.0064) bed-days per one resident in 2009-2011 to 0.007 (0.0069-0.0071) in 2012-2014 (p = 0.005).
The second period of observation was associated with the decreasing values of mortality after injuries and poisoning from 264.0 (243.4-248.6) to 202.5 (200.3-204.7) (p = 0.0001) per 100,000 persons (p = 0.982). The decreasing mortality from the external causes was from 306.2 (304.6-307.8) to 262.6 (261.1-263.9) (p = 0.0001) at the background of the increase in the mortality after road traffic accidents from 10.9 (10.8-11.0) to 17.4 (17.3-17.5) (p = 0.0001).
The development of medical rehabilitation favored the increase in availability of rehabilitation treatment, the quality of arrangement of medical assistance and efficiency of treatment.
There are some perspectives of increasing volume of high tech aid with higher availability for the unprotected population:
- as for hip joint replacement, to extend the list of specialized operations realized in the territory of Kemerovo region, including reconstructive and plastic operations for defects and development defects of the extremities and the spine, osteomyelitis, particularly, with application of external fixation devices, vertebral prosthesis and intervertebral disk ones and osteooncology;
- to continue the implementation of the internal fixation techniques, particularly, with the European technologies;
- to increase the volume of videoendoscopic operations in traumatology and orthopedics.
Specialized medical rehabilitation in hospital conditions (the stage 2) is realized for trauma patients with use of 88 beds including:
- Gorbunova City Clinical Hospital No.1, Kemerovo – 10 beds;
- Regional Clinical Orthopedic and Surgical Hospital for Rehabilitation Treatment, Prokopyevsk – 40 beds;
- Novokuznetsk Scientific and Practical Center of Medicosocial Expertise and Rehabilitation for Disabled Persons – 38 beds.
Considering the sufficient provision of rehabilitation beds in the southern part of Kemerovo region, it is required to increase the volume of hospital traumatological treatment for the residents of Kemerovo and its districts.
In 2018 it is expected to extend the services of medical rehabilitation up to 20 beds on the basis of Gorbunova City Clinical Hospital No.1, Kemerovo, with development of the fully-featured department for the population of the northern part of Kuzbass.
At the third stage (2015-2020) it is expected to open 5 departments of outpatient medical rehabilitation on the basis of the trauma centers (Anzhero-Sudzhensk, Kemerovo, Belovo, Mezhdurechesk, Yurga) and 8 rooms (Kemerovo, Kiselevsk, Novokuznetsk, Prokopyevsk, Tashtagol, Mariinsk, Promyshlennaya and Yashkinsky regions).
The departments and the rooms of rehabilitation will be equipped in concordance with the orders of arrangement of medical rehabilitation confirmed by the order by Russian Health Ministry.
CONCLUSION
1. On the basis of the developed examination technique, the requirement of the population in rehabilitation has been estimated. It has provided the perspective for development of the network of medical facilities and regional use of the bed reserves.
2. The costs for restoration of the lost functions of the body have been minimized by means of the system approach to solution of the problems of efficient management of protection and promotion of public health.
3. Management of provision of medical aid quality (also by means of stimulating the material and technical resources in medical facilities and adherence of to the requirements of medical rehabilitation arrangement) has optimized the system for training medical staff.
4. The efficiency of the system of innovative technologies in arrangement of medical rehabilitation was estimated with two three-year periods of observation (2009-2011 and 2012-2014). The estimation has confirmed the appropriateness of restructurisation of bed fund by means of increase in the number of rehabilitation beds and provision of rehabilitation for adults and children in hospital and outpatient conditions that has favored the increasing number of persons with improving health and has confirmed the presence of medical efficiency of improvement in rehabilitation.
5. The mortality among the working age population has decreased from 870.0 in 2009-2011 to 783.0 in 2012-2014 per 100,000 of the relevant population (p = 0.0001). The morbidity with temporary loss of working capability has decreased from 48.5 to 42.9 (p = 0.0001).
The primary disability has decreased from 101.4 in 2009-2011 to 75.4 in 2012-2014 (per 10,000 working age persons). The level of pediatric mortality showed the similar trends: 26.2 in 2009-2011 to 24.5 per 10,000 in 2012-2014 (p = 0.0001).
The amount of complaints and visits concerning arrangement and quality of medical aid has decreased from 47.8 in 2009-2011 to 11.5 in 2012-2014 (p = 0.001). The satisfaction with quality of medical aid has increased from 62.2 to 65.5 (p = 0.006).
The above-mentioned values show the presence of social efficiency of the innovative technologies in arrangement of rehabilitation.
6. Realization of the perspective technologies of medical rehabilitation has favored the increase in structural efficiency of arrangement of medical aid and optimization of the mechanisms of its financial provision.