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ASSESSMENT OF THE QUALITY OF MEDICAL CARE IN OUTPATIENT SETTINGS. PATIENTS WHO HAVE SUFFERED A
STROKE
Akhmetov D.M.1, Aidarbekova D.A.2,Muratbayev A.Zh.3
1Akhmetov Dosymzhan Makhmutuly - general surgery doctor, CLINIC "EMIRMED", assistant,
DEPARTMENT OF GENERAL SURGERY, KAZNMUNAMEDAFTER. S.D. ASFENDIYAROV,ALMATY; 2Aidarbekova Dariga Asylbekovna - general practitioner, "CITY CLINIC NO. 5", ASTANA;
3MuratbaevAibolat Zhantilekuly - resident doctor in the specialty "Neurology", WEST KAZAKHSTAN UNIVERSITY NAMED AFTERMARAT OSPANOV, general practitioner, KARGALY CITY HOSPITAL,
AKTOBE; REPUBLIC OF KAZAKHSTAN
Abstract: the main job of an outpatient neurologist and a district therapist in providing medical care to stroke patients is to carry out rehabilitation measures. It 'was found that in the polyclinic, the predominant proportion of stroke patients are patients who are observed during the recoveryperiod and, accordingly, have the greatest rehabilitationpotential. Keywords: Kazakhstan, cerebrovascular pathology, health.
ОЦЕНКА КАЧЕСТВА МЕДИЦИНСКОЙ ПОМОЩИ В АМБУЛАТОРНЫХ УСЛОВИЯХ. ПАЦИЕНТЫ, ПЕРЕНЕСШИЕ
ИНСУЛЬТ
Ахметов Д.М.1, Айдарбекова Д.А.2, Муратбаев А.Ж.3
1АхметовДосымжан Махмутулы - врач общей хирургии, клиника «ЭмирМЕД», ассистент, кафедра общей хирургии, КазНМУ им. С.Д. Асфендиярова, г.Алматы; 2Айдарбекова Дарига Асылбековна - врач общей практики, «Городская поликлиника № 5», г. Астана; 3Муратбаев Айболат Жантилекулы - ординатор-врач по специальности «Неврология», Западно-Казахстанскийуниверситет имени Марата Оспанова, врач-терапевт, Каргалинская городская больница, г. Актобе; Республика Казахстан
Аннотация: основной задачей амбулаторного невролога и участкового терапевта при оказании медицинской помощи больным, перенесшим инсульт, является проведение реабилитационных мероприятий. Установлено, что в поликлинике преобладающую долю больных с инсультом составляют пациенты, наблюдающиеся в период восстановления и, соответственно, имеющие наибольший реабилитационный потенциал.
Ключевые слова: Казахстан, цереброваскулярная патология, здоровье.
UDC 616.831-005.1
Introduction. In recent years, the system of medical care for patients with acute cerebral circulatory disorders has been actively developing in our country, which is associated with a significant proportion of cerebrovascular pathology in the structure of morbidity, disability and mortality of the population. Stroke causes serious economic damage to society and significantly reduces the quality of life of patients - this determines the need to improve medical care for both patients with stroke risk factors and those with already developed acute cerebral circulatory disorders. The standards and procedures currently developed and approved for the provision of medical care for acute cerebral circulatory disorders regulate the provision of inpatient care to patients with this pathology and, to a lesser extent, outpatient outpatient care, which is important for the rehabilitation of stroke patients.
The purpose of the study: to identify areas of inefficiency in the provision of outpatient medical care to patients with acute cerebral circulatory disorders and their consequences.
To achieve the goal, the following tasks were formulated:
1) to analyze compliance with the procedure for the management of patients with acute cerebrovascular accident and their consequences
2) determine the degree of compliance of outpatient medical care for stroke with the standard.
Materials and methods. The object of the study was medical care provided to patients with stroke on an outpatient basis.
According to the Procedure for providing medical care to patients with acute cerebral circulatory disorders, approved by the order of the Ministry of Health of the Republic of Kazakhstan, medical care to patients with acute cerebral circulatory disorders is carried out sequentially:
1) at the pre-hospital stage (by ambulance teams),
2) in inpatient conditions (specialized departments),
3) in outpatient clinics or other institutions, depending on the clinical characteristics and functional capabilities determined by points on the Rivermead mobility scale. At the end of the inpatient stage of treatment, the following are sent to the outpatient stage: for observation in the polyclinic - patients after acute cerebrovascular accident with minimal motor and other deficits, fully self-serving (at least 8 points); for observation at home -patients after acute cerebrovascular accident with significant impairments of motor and other functions, not moving independently and requiring constant care (1 point or less). Patients can also be sent to medical and physical education dispensaries (at least 8 points on the Rivermead scale), to sanatorium-resort institutions, centers, including scientific and practical (at least 4 points), and rehabilitation departments, resort hospitals and specialized restorative treatment (less than 4 points), geriatric institutions, homes nursing care and hospices (1 point or less). The standard of medical care for stroke patients in the conditions of outpatient care was approved by the order.
The data obtained by copying from medical records were included in the original chart, which includes the following sections:
1) passport part (gender, age, disability, type and period of stroke),
2) information on the conditions of medical care for patients with acute cerebrovascular accident and their consequences (specialists of which medical institutions carried out the diagnosis and treatment of stroke),
3) information on the volume of medical services and prescribed medication in the polyclinic for stroke.
Methods of mathematical statistics were used for processing: parametric (Student's t-test), nonparametric (correlation analysis), calculation of relative values, the use of the analytical method allowed to substantiate the conclusions.
Results. In the sample, patients were distributed by gender as follows: men 57.5%, women 42.5%; by age: 70% are retired, 30% are able-bodied. The structure of stroke was dominated by cerebral infarction (92%), the proportion of hemorrhagic and mixed stroke was 4% each. 27.5% of stroke cases were repeated. At the time of the study, the proportion of patients observed in urban polyclinics in the acute period (up to 28 days) was 2.5%, in the early recovery period (up to 6 months) - 25%, in the late recovery period up to 1 year -22.5%, in the late recovery period up to 2 years - 37.5% (total in the recovery period 85%), in the residual period of residual effects (after 2 years) -12.5% (Drawing. 1).
12,5% 2.5%
37.5% 22.5%
Drawing. 1. Distribution ofpatients under the supervision of a neurologist in a polyclinic by stroke
periods (in %).
We studied the observance of the Procedure for providing medical care to patients with acute cerebrovascular accident in terms of measures performed at the outpatient stage. According to regulatory legal documents, the provision of medical care to patients with acute cerebrovascular accident should begin at the pre-hospital stage by emergency medical teams. In 40% of the studied cases, acute cerebrovascular accident was diagnosed first by outpatient specialists, of whom: in 12% of cases - neurologists of the polyclinic, in 28% -first district therapists and subsequently - neurologists of the polyclinic. In 34% of cases, patients were not hospitalized in the acute period of stroke in specialized departments of the round-the-clock hospital, medical care was provided to them by specialists of the polyclinic at home. This indicator had no statistically significant differences in the groups of patients with first-time and recurrent stroke. The current Procedure provides for the provision of medical care to patients with acute cerebral circulatory disorders after the pre-hospital stage in inpatient conditions of medical institutions and only then in outpatient clinics. In 76% of cases, patients after the end of the acute period of stroke were observed in a city polyclinic by district therapists or neurologists. There were no statistically significant differences in the proportion not observed in the groups hospitalized in a 24-hour hospital in the acute period and receiving outpatient medical care, as well as in the groups of first-time and recurrent strokes. In 4% of cases, according to medical documentation, patients after a stroke were not
consulted by a neurologist at any time, either in acute or in subsequent periods. The quality of outpatient medical care provided for stroke was studied based on a comparison of the standard and actual volumes of medical services and drug therapy for stroke patients. We analyzed the implementation of the standard in terms of providing medical services for the rehabilitation of a stroke patient for 6 months.
The actual frequency of providing the service "neurologist's appointment (dispensary, preventive)" for 6 months averaged 0.96, which is lower than the standard .The analysis of the implementation of the standard in terms of the average number of services provided "neurologist's appointment (dispensary, preventive)" was carried out only in a group of patients who had a stroke 6 months ago or more (78% of the studied population) due to the characteristics of the standard used (provision of services at the rate of 6 months). The average number of presentations of the "neurologist's appointment" service according to the standard of outpatient care for stroke patients for 6 months is 6.0. The standard in this part was fulfilled in full and exceeded in 23% of cases. The average number of this service was 4.08. However, these indicators do not fully reflect the current situation, since there is an uneven distribution of service provision over time: in the group of patients who had a stroke 6 months ago or more, the proportion observed only in the first three months was almost two thirds (64%), observed during 6 months (early recovery period) - only a tenth (10.3%). In this regard, we conducted an additional analysis, as a result of which a strong inverse correlation was established between the period from the moment of stroke and the proportion of people who received the "neurologist's appointment" service (r=-0.89; p=0.02). Rehabilitation services for a patient who suffered an acute cerebral circulatory disorder, with a frequency of 1.0 and with a multiplicity of 6.0 at the rate of 6 months, they are not presented in the form of a specific list, which makes it difficult both to assign them and to evaluate their implementation. At the next stage, we analyzed the implementation of the standard in terms of prescribing recommended medicines. Acetylsalicylic acid preparations were prescribed with a frequency below the standard (the actual frequency is 0.43, according to the standard - 0.8), cerebrolysin (actually 0.05, standard - 0.2), the antidepressant fluoxetine was not prescribed (standard 0.25). Other types of antiplatelet agents (curantil with a frequency of 0.15), neuroprotective drugs (total frequency of administration 0.98), vitamins (frequency 0.25) and symptomatic agents (0.05) were prescribed in excess of the standard. The total actual frequency of prescribing antiplatelet agents (including combinations) of 0.53 turned out to be lower than the standard (0.9). The frequency of prescribing neuroprotective drugs (0.98) was almost five times higher than the frequency according to the standard (0.2). The static significance of the differences between the prescribed standard and the actual frequency of administration of antiplatelet agents and neuroprotectors (p<0.01) has been established.
Discussion.The studied sample of stroke patients reflects the main characteristics of the general population. The results obtained are consistent with the literature data on the proportion of people of working age among stroke patients, the frequency of recurrent acute cerebral circulatory disorders, a higher prevalence of stroke among men and the predominance of cerebral infarction in the stroke structure. The data obtained made it possible to identify the main directions for improving the quality of medical care for stroke patients. It is necessary to improve the system of medical care for patients of working age, whose share in the structure of patients with acute cerebrovascular accident reaches a third and continues to increase. Also, in the structure of acute cerebrovascular pathology, there is an increase in the number of ischemic cerebral circulatory disorders. Active tactics of prevention and restoration of lost functions, taking into account pathogenetic mechanisms. The main job of an outpatient neurologist and a district therapist in providing medical care to stroke patients is to carry out rehabilitation measures. It was found that in the polyclinic, the predominant proportion of stroke patients are patients who are observed during the recovery period and, accordingly, have the greatest rehabilitation potential. The existing Procedure for providing medical care to patients with acute cerebrovascular accident from
2020 defines the role of the outpatient stage, indicating which groups of patients are sent to the polyclinic after discharge from the hospital. In practice, in addition to measures for the rehabilitation of stroke patients, outpatient polyclinic organizations also perform the functions of emergency medical care and hospitals of medical institutions. Medical care in polyclinic organizations for strokes is regulated by a single concise and generalized standard that includes a set of services for all phases and stages of the disease. Our study revealed structural imbalances in the implementation of this standard, which consist in active monitoring of patients in the first 3 months after the development of stroke and a low level of follow-up examination; when prescribing medicines, the imbalances consist in a decrease in the proportion of drugs recommended by the standard when using drugs that are not reflected in the standard. The inclusion in the standard of a specific list of rehabilitation services (or the creation of a separate standard or procedure for the rehabilitation of patients after stroke) and the elimination of structural imbalances in the implementation of the existing standard will improve the quality of medical care for this category of patients.
Conclusions
1. Outpatient polyclinic organizations, in addition to their own functions, perform the functions of the pre-hospital and inpatient stage of the process of providing medical care to patients with acute cerebral circulatory disorders, which requires a change in the regulatory framework governing the provision of medical care to this category of patients.
2. When providing medical care at the outpatient stage, the frequency and frequency of follow-up of stroke patients is lower than the norm. A strong inverse correlation was established between the period from the moment of development of acute cerebrovascular accident and the proportion of people who received the "neurologist's appointment" service (r=-0.89; p=0.02).
3. Structural imbalances were revealed in the implementation of the drug component of the standard of outpatient medical care for stroke patients: the actual frequency of prescribing antiplatelet agents for the prevention of recurrent cerebral circulatory disorders and antidepressants is lower than provided by the standard, the appointment of neuroprotective drugs is higher than recommended by the standard.
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