ASSESSMENT OF ACCESSIBILITY AND QUALITY OF MEDICAL REHABILITATION IN THE KEMEROVO REGION 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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