德国私人医疗保险对医疗服务及健康自我评估的影响

在德国,公司员工通常都必须加入公共医疗保险系统.该系统覆盖面广,共付医疗费和自付费用合理,保险费基于收入计算,如果收入超过强制参保的最高限额则可选择购买私人医疗保险.保险费是由年龄和健康状况决定的,个人可选择接受保险的程度,共付费用和自付费用是普遍存在的.学者就私人医疗保险覆盖范围对参保者就诊次数、住院天数和健康自我评...     

扩大脆弱人群健康保险覆盖率的策略：描述性系统评价

目的描述扩大脆弱人群健康保险覆盖率的策略及作者对实施这些策略的评价。方法由主题专家和检索人员讨论并试验后确定检索词，共检索28个电子数据库、12个卫生机构网站、3个灰色文献数据库和搜索引擎Google。纳入所有描述或评价已经实施的扩大脆弱人群健康保险覆盖率策略的文献。用预先设计的数据提取表收集文献内容和有关研究质量的信息，分析和描述提取信息。结果共纳入86篇文献，大多研究来自美国，主要研究人群是儿童。61篇描述策略，25篇评价策略。据卫生筹资机制理论分析，扩大健康保险的策略分为六类，即改变健康保险的入保资格、提高对健康保险的认知度、合理设置保险金水平、改进入保程序、改善卫生服务提供、改善保险的管理和组织。评价策略的研究大部分为回顾性纵向数据分析，仅有两篇为随机对照试验。评价研究的结论是所实施的策略对扩大保险覆盖有正面效应。结论美国等发达国家已实施大量策略用于扩大健康保险覆盖率，发展中国家实施的策略和相关研究均较少，发达国家实施的策略对发展中国家有一定的借鉴意义。纳入文献中有25篇评价策略效果的研究，可做进一步的系统评价，以考察策略对扩大健康保险覆盖率的效果。     

中低收入国家不同医疗保障制度设计对抵御疾病经济风险的作用研究

目的采用系统评价的方法对中低收入国家不同医疗保障制度抵抗经济风险的制度安排进行总结和描述；对制度安排所产生不同效果的原因进行分析。方法由主题专家和检索人员讨论并试验后确定检索词，共检索24个电子数据库、11个卫生机构网站和搜索引擎Google。纳入所有对中低收入国家医疗保障制度对抵御疾病经济风险进行评价的原始研究。按预先设计的数据提取表采集纳入文献的相关信息，而后加以分析和描述。结果所纳入52篇文献中，能够抵御疾病经济风险的56个制度设计归结为以下六类：①社区医疗保险；②社会医疗保险；③卫生部门改革；④补助型保障；⑤使用者付费；⑥中国新型农村合作医疗。其中，42个的制度设计对抵御疾病经济风险有正性作用，6个有负性影响，5个没有影响，2个影响不明确。结论中低收入国家能够有效抵御疾病经济风险的制度设计归结为：自付比例的设置方式，服务包的范围和内容，对特定人群提供免费服务，在卫生服务可及性差的地区建立初级卫生保健团队和中国的新型农村合作医疗制度。对低收入人群抵御疾病经济风险起到有效影响的制度有：国家为穷人购买保险、向穷人提供免费服务和根据收入水平规定不同的费用自付比例。制度设计对抵御疾病经济风险没有发生作用的原因是，由于制度内和制度外多种因素的制约，而使制度在运行过程中偏离了初始目标。     

成本分摊机制的引入对参保人群影响的系统评价

目的系统评价成本分摊机制的引入对参保人群的影响,为更好地设计医疗保险方案中的成本分摊方法提供科学依据。方法由主题专家和检索人员讨论并预试验后确定检索词,共检索综合类、卫生类、经济类、社会学类及灰色文献数据库20个,纳入所有描述或评价已实施的成本分摊机制对参保人群卫生服务利用、经济负担和道德风险影响的文献。用预先设计的数据提取表收集文献内容和有关研究质量的信息,而后对所提取信息进行定性分析和描述。结果共纳入73篇文献,涉及澳大利亚、加拿大、中国等17个国家。统计分析结果显示:①成本分摊机制广泛应用于各种医疗保险项目,目标人群包括一般人群、老人、穷人、慢性病患者、儿童等,覆盖的服务包括门诊、住院、精神疾病服务、预防服务和药物治疗等。②成本分摊政策带来的影响包括:从全面付费到成本分摊政策,提高了发展中国家参保人群卫生服务利用的可及性,并在一定程度上减轻了其经济负担;发达国家实施从全免费到成本分摊政策,在一定程度上减少了卫生服务过度利用,但没有降低项目成本,并且基本卫生服务利用或者基本药物依从性的降低却带来了一些不良影响。     

临床路径在哮喘儿童中应用效果的Meta分新

目的 评价临床路径在哮喘儿童中的应用效果.方法 计算机检索PubMed、Cochrane Library、Ovid、ScienceDirect、EBSCOhost、中国知网(CNKI)、万方数据库、中国生物医学文献服务系统(CBM)8个数据库中关于临床路径应用于哮喘儿童的相关文献,同时辅以手工检索,检索时间1980年至2014年.由2名研究者独立地鉴别筛选文献、提取资料和评估文献偏倚,采用Revman 5.2软件进行数据合并分析.结果 共检索了1 048篇,实际纳入11篇文献,共2 207例哮喘儿童,临床路径组1 174例,对照组1 033例,Meta分析结果显示,实施临床路径的哮喘儿童住院时间较对照组有所缩短,所花的费用亦有所减少,急诊就诊次数低于对照组,健康教育效果好于对照组,差异有统计学意义;临床路径组哮喘儿童住院率比对照组有所降低,但差异无统计学意义.结论 临床路径对于减少哮喘儿童平均住院时间、平均医疗费用、降低急诊就诊次数和提高健康教育效果方面具有一定的现实意义.     

基于Web of Science数据库护理不良事件文献的计量学分析

目的 通过Web of Science数据库了解全球护理不良事件的整体状况,为今后相关研究提供参考。方法 检索Web of Science数据库收录的关于护理不良事件的文献,利用Web of Science及书目共现系统对检索结果从文献发表数量、杂志分布、作者、发文机构、国家等方面进行分析。结果 共检索到797篇文献,研究起步较晚,文献数量大体呈逐年上升趋势。刊载文献数量最多的期刊是《American Journal of Nursing》。发文最多的国家是美国。结论 本研究发现不良护理事件的研究还未引起广泛关注。目前研究主要探讨影响护理不良事件发生的因素以及上报制度的完善,但较少文献深入探讨护理不良事件发生的本质原因,未来应形成我国文化背景的指导管理理论,形成适合本土文化的不良事件管理模式,从而进一步构建护理不良事件的干预模型。     

我国临床高危药品安全管理的文献计量分析

[目的]分析国内关于高危药品安全管理的文献,揭示我国现有高危药品安全管理的现存问题及对策。[方法]以"安全管理"为主题词检索1994年—2014年中国期刊全文数据库(CNKI),以"高危药品"为主题词进行二次检索,下载文献并汇总分析。[结果]共检索文献126篇,逐篇阅读筛选出符合要求的文献29篇。[结论]我国对高危药品安全管理的研究尚处于探索阶段,构建科学的高危药品安全管理模式将有助于指导今后高危要安全管理工作的开展。     

氧化应激对糖尿病肾病时细胞、细胞外基质及血管通透性的影响机制

目的:糖尿病肾病及其引起的终末期肾病近年来在全球的发病情况逐年提高,该病预后差、治疗费用高,成为世界范围内严重危害人类健康的公共卫生问题。糖尿病肾病发病机制错综复杂,氧化应激被认为是重要的共同的机制之一。本文探讨氧化应激对糖尿病肾病的影响。资料来源:应用计算机检索MEDLINE,CBM,CNKI数据库及手工检索1997-01/2006-11期间的相关文献。包括临床研究(不限研究对象的年龄、性别、种族。)和基础研究,不限体内或体外研究。中文检索词包括“氧化应激”,“活性氧类”,“糖尿病肾病”和“发病机制”;英文检索词有“diabetic nephropathies”,“oxidative stress”,“reactive oxygen species”,“PKC”和“TGF-β”。资料选择:共收集到相关文献991篇,阅读全部文章的文题和大部分文章的摘要。选择文献所述内容与糖尿病肾病时氧化应激作用相关的文献。排除重复性研究和Meta分析类文章。资料提炼:共得到符合纳入条件的文献142篇,排除849篇。选择其中30篇进行分析,其中英文25篇,中文5篇,英文有1篇为手工检索的增刊。资料综合:糖尿病肾病的发病机制错综复杂,肾脏的结构和功能变化包括高滤过、肾脏和肾小球的肥大、细胞外基质的堆积、肾小球基底膜的增厚和肾小球滤过屏障功能的异常。这些变化是多因素共同作用的结果,在众多发病机制中,氧化应激被认为是共同机制之一。在正常情况下,活性氧的产生和抗活性氧水平二者处于平衡状态,当活性氧蓄积过多就会攻击机体,即氧化应激。氧化应激的产生主要是活性氧类产生过多和清除减少以及糖尿病肾病患者体内氧化应激水平增加导致的。氧化应激对糖尿病肾病的影响包括活性氧类可以增加细胞膜的通透性;使肾细胞内的谷胱甘肽过氧化物酶、超氧化物歧化酶和过氧化氢酶等抗氧化酶发生糖化或氧化,肾组织抗氧化能力降低,细胞内关键酶和转运蛋白Na-K-ATP酶失活等。结论:氧化应激作用可以增加细胞膜的通透性,使肾组织抗氧化能力降低,是糖尿病肾病的重要发病机制之一。     

基于CiteSpace软件探讨生物反馈技术在康复医学中的研究现状

目的:基于CiteSpace软件探讨生物反馈在康复中的研究热点及趋势。方法:检索CNKI中有关生物反馈在康复中应用的相关文献,经格式转换后,利用CiteSpace软件进行年度发文量、作者、机构、关键词的分析。结果:共检索出1019篇文献,经人工筛选,剔除会议类文献77篇,共纳入文献942篇;图谱中共有126位作者被纳入...     

我国急诊医学核心期刊临床随机对照试验文献分析

目的:分析我国急诊医学核心期刊临床随机对照试验文献,了解其能否为临床循证医学实践提供真实可靠的证据。方法:对我国急诊医学核心期刊进行计算机检索,并从检索结果中筛选出临床RCT文献进行分析。结果:检出临床RCT文献702篇。393篇描述了诊断标准,占56%;702篇描述了纳入标准,占100%;266篇描述了排除标准,占38%;26篇样本含量≥100例,占3.7%;34篇描述了随机分配方法,占5%;19篇描述了随机分配方案隐藏情况,占3%;19篇清楚描述盲法采用情况,占3%;702篇描述设立了对照,占100%;231篇清楚描述基线资料,占33%;592篇干预措施描述清楚,占84%;624篇观测指标及终点指标描述清楚,占89%;267篇描述了毒副作用,占38%;305篇清楚描述随访时间,占43%;10篇清楚描述脱落失访情况,占1%;1篇描述了依从性,占0.1%;145篇统计分析完全正确,占21%。结论:我国急诊医学核心期刊临床RCT文献质量尚需进一步提高,以满足临床循证医学实践需要。     

Management of Newer Medications for Attention-Deficit/Hyperactivity Disorder in Commercial Health Plans

PurposeIn the United States, many individuals with attention-deficit/hyperactivity disorder (ADHD) pay for their medications using private health insurance coverage. As in other drug classes, private insurers are actively seeking to influence use and costs, particularly for newer and costlier medications. The approaches that insurers use may have important effects on patients’ access to medications. This article examines approaches (eg, copayments, prior authorization, and step therapy) that commercial health plans are using to manage newer medications used to treat ADHD and changes in approaches since 2003.MethodsData are from a nationally representative survey of commercial health plans in 60 market areas regarding alcohol, drug abuse, and mental health services in 2010. Responses were obtained from 389 plans (89% response rate), reporting on 925 insurance products. For each of 6 branded ADHD medications, respondents were asked whether the plan covered the medication and, if so, on what copayment tier each medication was placed and whether it was subject to prior authorization or step therapy. Measures of management approach were constructed for each medication and for the group of medications. Bivariate and multivariate analyses were used to test for association of the management approach with various health plan characteristics.FindingsThere was considerable variation across these 6 medications in how tightly they were managed by health plans, with newer medications being subject to more stringent management. The proportion of insurance products relying solely on copayment tiering to manage new ADHD medications appears to have decreased since 2003. Less than half of insurance products (43%) managed these 6 medications solely by use of tier 3 or 4 placement, and most of the remainder (48%) used other restrictions (with or without tier 3 or 4 placement). The average insurance product restricted access to at least 3 of the 6 brand-only medications examined, whether through copayment tier placement or other approaches. More ADHD medications were left unrestricted in health maintenance organization products than in preferred provider organization ones, products with internal or hybrid-internal contracts for behavioral health, those not contracting with pharmacy benefits managers, and those with for-profit ownership.ImplicationsMany plans have supplemented copayment tiering with other approaches, such as prior authorization and step therapy, to influence use and decrease costs. It may be that plans have found copayments to be less effective in redirecting use in this medication class. The effect on clinical outcomes was not examined in this study but should be prioritized using other data sources.     

Management of access to branded psychotropic medications in private health plans

BACKGROUND: In the past decade, health insurers have increased their reliance on cost control policies such as prior authorization and 3-tier formularies. Little is known about how these policies are being applied to psychotropic medications, many of which have low rates of patient adherence. OBJECTIVE: This study reports on plans' cost-sharing tier placement and authorization policies for 12 brand only psychotropic medications in 3 classes: antidepressants, anti-psychotics, and medications for attention deficit/hyperactivity disorder (ADFID). METHODS: Data were from a nationally representative survey of private health plans regarding mental health and substance-abuse services in 2003; 368 plans responded (83% response rate). Results were weighted and represent national estimates of health-plan characteristics. RESULTS: The majority of insurance products provided unrestricted placement on Tier 2 (medium copayment) for at least 2 brand-only antidepressants and at least 2 brand-only antipsychotics. This approach allows clinicians some limited leeway in initial medication selection. However, most patients who did not respond to the Tier-2 options typically faced a substantial escalation in copayment (Tier 3), possibly leading to premature medication discontinuation. For ADHI)5 the options were considerably more limited, with 22.1% of products applying some restriction to all 3 medications and only 15.9% of products leaving all 3 medications unrestricted. Plans with specialty contracts for mental health were considerably more likely to use Tier 3 (highest copayment) as their only restriction approach. CONCLUSIONS: Based on the results of this analysis,private plans were managing psychotropic costs using copayment incentives rather than administrative controls. This approach was less intrusive for clinicians, but resulting higher copayments could worsen already high rates of nonadherence; future research should examine this issue.     

Effects of cost sharing on seeking outpatient care: a propensity-matched study in Germany and Switzerland

Background Several studies have assessed the effect of cost sharing on health service utilization (HSU), mostly in the USA. Results are heterogeneous, showing different effects. Whereas previous studies compared insurants within one health care system but different modes of insurance, we aimed at comparing two different health care systems in Europe: Germany and Switzerland. Furthermore, we assessed the impact of cost sharing depending on socio‐demographic factors as well as health status. Methods Two representative samples of 5197 Swiss insurants with and 5197 German insurants without cost sharing were used to assess the independent association between cost sharing and the use of outpatient care. To minimize confounding, we performed cross‐sectional analyses between propensity score matched Swiss and German insurants. We investigated subgroups according to health and socio‐economic status to assess a potential social gradient in HSU. Results We found a significant association between health insurance scheme and the use of outpatient services. German insurants without cost sharing (visit rate: 4.8 per year) consulted a general practitioner or specialist more frequently than Swiss insurants with cost sharing (visit rate: 3.0 per year; P < 0.01). Subgroup analyses showed that vulnerable populations were differently affected by cost sharing. In the group of respondents with poor health and low socio‐economic status, the cost‐sharing effect was strongest. Conclusion Cost‐sharing models reduce HSU. The challenge is to create cost‐sharing models which do not preclude vulnerable populations from seeking essential health care.     

Implications of current procompetitive approaches on EDs

Health reform is now predicted to occur in the marketplace without much further governmental intervention. The major vehicles driving this fortuitous trend are the managed care plans, capitated payment, and the development of complex and fiscally awesome health networks organized by hospitals, physicians, and health insurance companies. In the context of this procompetitive environment, potential decreases are projected in current emergency department (ED) volumes, demand for emergency medicine (EM) physicians, and anticipated workload and remuneration of doctors working in EDs. Eventually, mandated universal insurance for 260 million Americans will create a slight increase in total ED visits; additional cost constraints will force the closure of a number of hospital EDs; and EM specialists will experience less ideal working conditions, requiring them to work more hours to maintain their current incomes.     

A hitchhiker's guide to competitive managed care

Competition among managed care plans features the dynamic interaction among three primary forces: delivery system integration, managed care health plan risk sharing, and purchaser activism. To evaluate the cost containment potential for a particular market, decision makers need to understand the character of provider integration, the role of managed care insurance plans, and the extent of purchaser activism in contracting with health care providers. This paper provides benchmarks that analysts can use to assess markets, and applies them to the four largest markets in Wisconsin. It concludes that competition among managed care plans can lead to cost-effective care only if purchasers respond to differences in cost, for given quality, by switching from high-priced plans to lower-priced ones.