Добавка к теме не по теме...

The Lancet Volume 367, Issue 9514 , 18 March 2006-24 March 2006, Pages 919-925
Quality of hospital care for children in Kazakhstan, Republic of Moldova, and Russia: systematic observational assessment

Background
Major concerns about the quality of basic hospital care for children have been raised in developing countries, but no formal assessment applying international standards has been done in the Commonwealth of Independent States.

Methods
We assessed 17 hospitals in Kazakhstan, the Republic of Moldova, and the Russian Federation with a generic WHO hospital assessment framework adapted for use in the WHO European region. WHO management guidelines for paediatric care in peripheral hospitals were used as standards.

Findings
Hospital access for children was generally good. Good health networks existed, and skilled and committed doctors cared for children. Case-fatality rates were low. However, unnecessary and lengthy hospital stays were common, and most children received excessive and ineffective treatment (in one country median number of drugs prescribed concurrently was 5, IQR 2–6). Several conditions were systematically overdiagnosed, especially neurological disease, or overinvestigated, such as acute diarrhoea. Reasons for these practices included absence of clear evidence-based clinical guidelines, regulations tying duration of admission to financial reimbursement, generalisation of disease-control methods from rare problems to common illnesses, and regulations maintaining financial and professional status of some subspecialties. Many disincentives to efficient practice existed.

Interpretation
To improve quality of hospital care for children in the Commonwealth of Independent States, several issues must be addressed, including: adoption of international guidelines for inpatient management; complementary guidelines for outpatient management; reforms to health regulations governing admission and discharge criteria; improvement of quality of training, availability of medical information, and systems to promote and certify quality of care.
Discussion
Although in many less developed countries the quality of paediatric care is characterised by poorly structured health networks, and by unavailability of drugs and other resources,8, 9 and 10 the three countries we assessed in the CIS had good health networks and adequate numbers of staff. The problems of paediatric care that we identified in Kazakhstan, the Russian Federation, and the Republic of Moldova related more to excesses of treatment, overdiagnosis, and overhospitalisation. The reasons for these difficulties are complex. That most problems were found in all three countries was indicative of the similar systems of health organisation, legislation, medical education, and sub-specialisation. Our findings are probably generalisable to other countries in the region, an assumption supported by our informal meetings with medical personnel from the CIS.

The practice of giving too many drugs at once relates to numerous and cumbersome treatment protocols, some written as early as the 1960s. These protocols recommend many drugs that are now known to be ineffective or dangerous for general use in children. Doctors in CIS found these protocols confusing; many questioned the value of recommendations, and wanted clearer guidelines. Although the doses prescribed were often low, a risk of dose errors and interactions exists when several drugs are given together. While some treatments were enshrined in local disease-specific protocols (recorded in pricazes), others, such as antihistamines, were generally given to almost all inpatients. Further reasons for polypharmacy were financial incentives and parental expectations, often fuelled by sub-specialists prescribing drugs to treat trivial conditions or symptoms due to normal behaviour in infants; if prescribed by one doctor, why not another? For some unconventional treatments, such as electrical therapies for neurological disorders and fluorescent light therapy for tonsillitis, there was genuine belief in their value among some treating nurses and doctors, and a pricaz prescribed the treatments.

Absence of regulation of pharmacies contributed to unnecessary use of multiple drugs, and passed the costs for these treatments onto patients and their families. Some antidiarrhoeal drugs were strongly promoted by drug companies, and some of the clinical guidelines were brochures sponsored by drug companies. Having multiple privately run pharmacies that practiced shared price-fixing within an individual hospital resulted in inflated rather than competitive drug costs. Drugs were much more expensive in the rural areas than in the cities. A few hospitals had maintained their own non-privatised pharmacies: these seemed to have the least problems with availability of essential drugs.

Several oblasts had official audit systems that examined whether local pricazes have been followed. Some hospitals were required to send case-records of all deaths to government officials on a regular basis.

Lengthy and unnecessary hospitalisation is a complex issue with many underlying causes. In Kazakhstan, most primary health-care workers follow a former pricaz that any infant with any illness needs to be admitted. Although this practice is at variance with IMCI guidelines, which have also been adopted by official pricazes, the former pricaz has not been repealed. Insurance regulations in the Russian Federation govern duration of hospital stay—eg, 45 days for septicaemia, 9 days for upper respiratory tract infection, and 15 days for asthma. If the child is discharged before this period of time the hospital may not be reimbursed. The traditional need for prolonged isolation of patients with tuberculosis, leprosy, and other infections to protect the rest of the community is generalised in pricazes to the management of trivial viral illnesses and readily treatable bacterial infections. Fear of the punitive consequences by authorities for medical mistakes or not having full hospitals was a driving force for prolonged and unneccessary hospitalisations.

The statutory requirement for excessive investigation leads to lengthy hospital stays for many children. For diarrhoeal disease, a pricaz requires three stool samples to be clear of communicable pathogens, including Salmonella typhi. This requirement is one reason for under-reporting and excessive admissions for children with viral gastroenteritis. Stringent regulations about laboratory specimens also applied to other conditions: a teenage girl with Guillain-Barré syndrome was hospitalised for 5 months while waiting for exclusion of poliomyelitis, 1 month after all symptoms had resolved; children with hepatitis in the Russian Federation must remain in hospital until hepatic transaminase levels become normal.

Some otherwise well children were admitted because other effective social services were unavailable. Admission was often a kind act of goodwill by health workers in an effort to provide a safe environment for abandoned or orphaned children. However, the hospital stay often lasted weeks or months, and these children were frequently left alone for most parts of the day in a poorly stimulating environment.

In CIS, strategies to improve the quality of care need to simultaneously address several issues, including the absence of evidence-based approaches to clinical decision-making, the shortage of access to international standards and simple medical information, the organisation of hospital care, and disincentives for more efficient practices. Strategies need to be consistent with the processes of health reform taking place in the three countries, but could include: adaptation and implementation of WHO hospital guidelines for paediatric care; incorporation of standardised approaches to clinical practice and essential drugs into broader strategies of health-education reform and training;11 reforms to health regulations governing admission and discharge criteria and investigations; pharmacy regulation; and incentives for hospitals complying with good practice standards. Reforms should address the greater problems in delivering child health services in rural areas,12 and should take the opportunity to redevelop hospitals as core social institutions that not only provide high quality care, but also reduce the effects of poverty and social disadvantage on health and development.1

The commitment from paediatricians and other key professionals in CIS to public child-health services and reform suggests substantial opportunities for success.