ANALYSIS OF MEDICAL CARE PROBLEMS AND SELECTION OF RATIONAL MEASURES TO REDUCE ADVERSE OUTCOMES IN UROLOGICAL PATHOLOGIES

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Relevance. The development of urology as a clinical discipline, the emergence of new modern methods of diagnosis, treatment, the level of training of specialists contributed to a change in the structure of the organization of urological care to the population, aimed at reducing the main types of adverse outcomes of medical care, such as disability and mortality.

The aim of the study is to identify the currently accessible and relevant organizational aspects of the impact on the controlled causes of premature mortality and adverse outcomes of medical care.

Materials of the study. Patients of medical organizations of the Voronezh region of inpatient and outpatient polyclinic type, medical documentation, analytical reports of the Departments of Health and the Ministry of Health of the Russian Federation, Official information sources on the problem.

Research methods. Historical analysis, collection of complaints and anamnestic data of patients, sociological (questionnaire), content analysis of medical documentation and official information sources, statistical.

Results. The organization of urological assistance to the population in our country has come a difficult and difficult way in the formation of independent discipline. In Russia, before the revolution of 1917, only four urological hospitals were organized, in Moscow, St. Petersburg, Kiev and Odessa. With the advent of Soviet power, urology began to develop rapidly. Urology teaching has been introduced at all medical faculties and then medical institutes. There were urological departments, clinics, outpatient appointments. Methods of diagnosis and treatment of urological diseases have been improved. The area of interest in urology was constantly changing at different stages of its development. But the reduction of premature death and adverse outcomes of medical care is the main direction of the organization of medical care in the Voronezh region [4].

There are two groups of causes of premature mortality and adverse outcomes of medical care. The first are managed, related to factors that could have been avoided or influenced. These include: the nature of treatment (view, volume, timeliness, completeness, adequacy), prevention, rehabilitation, diagnosis, competence of specialists, personnel, economic, technical and organizational support. Unmanageable, associated with factors when such avoidance or impact is impossible. These are age, incurable nature of the disease, trauma incompatible with life, "random events".

During the study of the problem, among the specific organizational aspects available for use to influence the controlled causes of premature mortality and adverse outcomes of medical care, the following first of all drew attention to the following: identification of pathology, timeliness and accessibility of medical care, duration of the conservative stage of treatment, operational activity, application of minimally invasive high-tech interventions, level of training of specialists in applied aspects of medical care, level of medical literacy among the population, standardization of medical care, ergonomics and informatization of planning and control of organizational measures.

To implement the impact on the identified relevant organizational aspects, a program of organizational measures "three-level system of medical care" was developed and applied. This program included the following tools: a system of diagnosis of risk groups, a clear system (protocols) of standardization of diagnostics / treatment, routeing of patients, adapted educational and methodological complex, definition of key performance indicators, information and analytical support system [1]. Until 2011, the functioning of the urological service in the Voronezh region was carried out according to a two-level system. The first level is district medical organizations, the second urological department of Voronezh Regional Clinical Hospital No. 1. This system of organization of medical care reduced one of the key indicators of the quality of medical care, namely, the timeliness and availability of urological care to residents of the districts of the region. As a result, the entire subsequent chain of events led to a decrease in the impact on the controlled causes of premature mortality and adverse outcomes of medical care. If we consider the above model on a practical example, it looked like this: the patient made urological complaints to the polyclinic to the therapist or in the presence of a urologist/surgeon. Further, the outpatient specialist, according to indications, and sometimes due to the lack of the possibility of urological care due to the lack of the necessary diagnostic base, low competence of the specialist, referred the patient to the inpatient stage of examination and treatment. For the same reasons, district hospitals and city hospitals were forced to send patients to VOKB No. 1, which led to an increase in the period of medical care, i.e. timeliness and accessibility. In another case, there was an excessive workload of the beds of the urological department of VOKB No. 1, patients who could be treated at the polyclinic or district level. As a result of these and other reasons, "dysfunctional", "medium" and "prosperous" districts of the region in terms of the quality of urological care were formed in the Voronezh region. The largest number of districts in terms of ranking was occupied by "average" and "dysfunctional", the smallest number of "prosperous" 5 out of 32 districts of the region. Based on the above, a three-level system of medical care in urology has been introduced in the Voronezh region since 2011. The model is as follows: the first level - district medical organizations, the second - interdistrict urological centers, the third - the urological department of VOKB No. 1, which increased the availability of urological care to residents of the districts of the region, reduced the expectation of qualified, specialized and high-tech medical care, the urological departments of city hospitals of This was expressed in the following galaxies of effects [2].

1st galaxy of effects:

- Increasing the level of training of specialists (primary health care) on applied problems of medical care - by 43%.

- Increasing the level of medical literacy among the population - by 31%.

- Increasing the level of standardization - by 65%.

2nd galaxy of effects:

Level increase:

- active early detection (by 47.7%);

•Reasonable operational activity (by 9.3%);

•Reasonable use of minimally invasive and

High-tech interventions (by 55.9%);

• timeliness and availability of medical care;

- medical examinations (by 47.9%);

Level reduction:

- waiting periods and providing qualified medical assistance;

- unreasonably prolonged conservative treatment (by 22.3%);

- reduction in the detection of pathology at the already "launched stages" (by 47.7%).

3rd galaxy of effects:

- Reducing the level of temporary disability - by 1.3 times.

- Reducing the level of disability - by 2.7 times.

- Reducing the premature mortality rate by 2.1 times.

- Reduction of economic costs for diagnosis and treatment in terms of a specific patient - by 1.7 times.

Conclusions.

At the moment, some of the most relevant organizational aspects of the impact on the controlled causes of premature mortality and adverse outcomes of medical care available for correction are:

1) detection of pathology,

2) the duration of the conservative stage of treatment,

3) operational activity,

4) timeliness and availability of medical care,

5) the use of minimally invasive and high-tech interventions,

6) the level of training of specialists in applied aspects of medical care,

7) the level of medical literacy among the population,

8) standardization of medical care,

9) ergonomics and informatization of planning and control of organizational activities.

Adaptive organizational impact on these parameters can fundamentally reduce the level of premature mortality and adverse outcomes of medical care in the population without increasing the economic costs of diagnosis and treatment in terms of a particular patient.

Available tools to help achieve this are optimally developed systems for diagnosing risk groups and standardization of diagnosis / treatment / routing of patients, educational and methodological complexes, key performance indicators controlled by information and analytical support systems.

Intermediate key performance indicators to be paid attention to are: active early detection, reasonable operational activity and the use of minimally invasive and high-tech interventions, unreasonably prolonged conservative treatment, timeliness and availability of medical care, medical examination.

About the authors

Anastasia Alekseevna Peshkova

Voronezh State Medical University named after N. N. Burdenko

Email: peshkova.anastassiya@yandex.ru
ORCID iD: 0000-0003-1332-0858

N.N. Burdenko VSMU, Department of Management in Healthcare

Russian Federation, 394036, Russia, Voronezh, st. Student, d. 10.

Dmitriy Nikolaevich Slusarev

Voronezh State Medical University named after N. N. Burdenko

Author for correspondence.
Email: slyusarev.04@list.ru
ORCID iD: 0000-0002-7183-9917

N.N. Burdenko VSMU, Department of Management in Healthcare

Russian Federation, 394036, Russia, Voronezh, st. Student, d. 10.

References

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