Determination of the Need for Inpatient Medical Care at the Municipal and Regional Levels and Ways of Its Maximum Satisfaction

The dissertation is devoted to the problem of the scientific substantiation of determining the population's need for inpatient medical care and the ways of its maximum satisfaction at the municipal and territorial levels. The study was conducted on the material of the major industrial city of Novokuznetsk and the Republic of Khakassia. The work develops methodological approaches to determining the need for hospitalization, taking into account the sex-age structure of the population, morbidity, societal losses from premature mortality, the public health index, and the level of environmental pollution at the place of residence.

During the research, a comprehensive assessment of the public health of the population was conducted, the existing system of medical care delivery and planning was analyzed, and conceptual approaches to the formation of municipal and state orders for inpatient types of medical care, taking into account explicit and hidden needs, were formulated. A model of a multilevel system of inpatient care delivery was proposed, including the optimization of hospitalization volumes by type and location of hospitals, and an automated information system for the management of municipal order formation was developed. The results have been introduced into the practice of healthcare in Novokuznetsk, the Republic of Khakassia, the Udmurt Republic, and other regions.

For the optimal functioning of any system, including the healthcare system, adequate planning of its activities is necessary, taking into account the demand for services. The problems of planning inpatient medical care have for many years been at the center of attention of leading scholars and healthcare organizers (E.A. Loginova, 1982, 1985; N.A. Kravchenko, 1985, 1998; A.G. Safonov, 1989; O.P. Shchepin, 1983; Yu.M. Komarov, 1982, 1997). The studies conducted by them concern methodological approaches to resolving this problem, which are largely of a regulatory nature at the federal level. However, to the present day, the problems of determining the population's need for medical care during the reform of healthcare remain unresolved.

At the current stage of development of our society, when decentralization of governance has occurred, a transition to multi-channel forms of healthcare financing is being carried out, and medical care is being provided by healthcare institutions (LHIs) with various forms of ownership, the scientific substantiation of the determination of the population's need for inpatient medical care and the improvement of its delivery methods become significantly more relevant for territorial and municipal healthcare.

The necessity of improving methodological approaches to determining the population's need, of the scientific substantiation of organizational forms of managing inpatient medical care based on the application of computing technology, economic-mathematical methods, and modeling methods, has been pointed out by many authors (S.A. Gasparyan, 1978, 1990; V.I. Kant, 1987; G.I. Chechenin, 1990; V.K. Ovcharov, 1996). However, their research addressed either the pre-reform period or the initial stage of healthcare reforms.

Methodological approaches to planning medical care at the territorial level during the introduction of medical insurance (N.B. Mel'yanchenko, 1993; G.N. Tsarik, 1999; V.I. Starodubov, 1994) concern primarily the technology of satisfying the need for medical care through the intensification of resource utilization.

An analysis of the proposed methodologies revealed that their basis is the population size, the assessment of the state of public health with some modification. As a rule, the morbidity rate of the population by healthcare utilization is most frequently used. However, during the transitional period of economic reform, when against the background of a deficit in financing for all sectors of the national economy there is observed a decline in the standard of living of the majority of the population and a deterioration of public health, the need of Russian citizens for medical care and the capabilities of the healthcare system have come into contradiction.

The reduction in healthcare utilization by the population for a number of reasons (fear of losing one's job, lack of interest in preserving one's health, problems of access to medical care, etc.) and the decline in the preventive orientation of LHIs due to a deficit of financing lead to the formation of diseases hidden from the view of the healthcare system, which results in the chronicity and aggravation of pathology, and increases the need for expensive inpatient care. This places an additional burden on the municipal healthcare system and is exacerbated in major industrial cities of Siberia, where against the background of ecological load and sharply continental climatic conditions the adaptive capacity of the organism is reduced, the risk of disease onset and exacerbation is increased, and the clinical picture of their manifestation is distorted.

Methodological recommendations for the formation of territorial programs of state guarantees for the provision of free medical care to citizens of the Russian Federation, developed in accordance with the Resolution of the Government of the Russian Federation of September 11, 1998, No. 1096, address individual aspects of need determination and are of a regulatory and reference character.

Thus, there arose a need to improve and scientifically substantiate the methodological approaches to determining the true need of the population for medical care, including inpatient care as the most expensive type, and to seek ways of its maximum satisfaction at the municipal and territorial levels through the intensification of resource utilization in the healthcare system, the introduction of new organizational forms and information technologies within the framework of the formation of municipal and state orders. This is especially important during the restructuring of healthcare, the introduction of a multilevel system of medical care delivery, and hospital-substituting technologies.

All of the above underscores the relevance and significance of the present study.

Goal and Objectives of the Study

The goal of the study is the scientific substantiation and development of the methodological basis for determining the population's need for inpatient medical care and ways of its maximum satisfaction at the municipal and territorial levels.

To achieve the stated goal, it was necessary to solve the following tasks:

1. Develop a methodology for the comprehensive assessment and analysis of the public health of the population, taking into account the sex-age structure, societal losses from premature mortality, and the level of environmental pollution at the place of residence.

2. Study and conduct a comparative assessment of the dynamics of public health indicators of the population of the city of Novokuznetsk (with allowance for its administrative districts) and the Republic of Khakassia (with allowance for its territorial units) across periods of healthcare reform.

3. Study the existing system of resource provision for the healthcare system of the city of Novokuznetsk and the Republic of Khakassia.

4. Substantiate the methodological basis for determining the population's need for various types of medical care (including inpatient), taking into account the sex-age structure, morbidity, societal losses from premature mortality, the public health index, and the level of environmental pollution.

5. Conduct an analysis of the problems of forming municipal and state orders for basic types of medical care, primarily inpatient, and determine ways of their optimal resolution.

6. Scientifically substantiate a model for the formation of municipal and state orders for inpatient types of multilevel medical care, based on refined population need and providing for the optimization of hospitalization volumes by type and location of hospitals (24-hour hospital, day hospital at a hospital, day hospital at a polyclinic, home hospital), through the intensification of resource utilization in the healthcare system and the introduction of new medical technologies.

7. Scientifically substantiate and develop a technology for the practical implementation of the proposed system of inpatient medical care delivery and assess the effectiveness of the proposed model.

8. Based on the proposed model, form optimal variants of municipal orders for the provision of inpatient types of medical care in the territory of the Republic of Khakassia and the city of Novokuznetsk.

Scientific Novelty of the Work

For the first time, from the standpoint of a systems approach, by periods of healthcare system development, the features of the health status of the population at the level of the major industrial city of Novokuznetsk and the territory of the Republic of Khakassia have been studied. The analysis was conducted taking into account the sex-age structure of the population and the public health index, obtained through the integration of five groups of indicators reflecting: the medical-demographic situation, morbidity, disability, physical development, and psychoemotional stress in society, and societal losses from premature mortality.

The scientific problem of developing a methodology for determining the population's need for medical care (including inpatient), taking into account not only morbidity but also the sex-age structure, societal losses from premature mortality, and the influence of the level of environmental pollution at the place of residence in the city of Novokuznetsk, has been resolved.

Approaches to the formation of municipal and state orders for inpatient types of medical care, taking into account the explicit and hidden needs of the population, have been developed, providing for the optimization of hospitalization volumes through the intensification of resource utilization in the healthcare system and the introduction of new medical technologies (within a multilevel system of medical care delivery) at the urban and territorial levels.

Adequate informational support has been created: information bases and an automated system for the management of inpatient medical care delivery.

A methodology for assessing the effectiveness of the functioning of the proposed system has been developed.

The developed methodology for determining population need and the model for the formation of municipal and state orders have been applied in the healthcare system at the city, district, and territorial levels, and allow for the modeling of situations and optimization of resource capabilities, taking into account the identified need of the population for specific services, which is especially important in conditions of reforming life-support systems.

Practical Significance of the Work

The results of the study have been introduced into the practice of the municipal healthcare system of the major industrial city of Novokuznetsk and have been used for a number of years (1995-2003) in the optimization of the system of inpatient medical care delivery based on the formation of municipal and state orders, the multilevel nature of treatment, and for the assessment of the effectiveness of measures undertaken (implementation act of October 1, 2003).

A two-level approach to the formation of municipal and state orders has been tested at the level of the Ministry of Health of the Republic of Khakassia and at the level of three of its territorial units: the city of Sayanogorsk, Askizsky District, and Beloyarsky District (implementation act of October 31, 2003).

The proposed methodology for determining the population's need for hospitalization and the resource provision of hospitals is used in the system of the Ministry of Health of the Udmurt Republic (implementation act of September 8, 2003).

Methodological materials on the organization of multilevel medical care delivery to the urban population are used at the City Clinical Hospital No. 1 of the city of Tolyatti since 2001 in the substantiation of the need for medical care and the formation of the municipal order (implementation act of August 20, 2003).

The proposed approaches to determining the population's need when forming municipal and state orders for inpatient types of medical care have found application in the departmental (railway) healthcare system of the city of Novokuznetsk, as well as in the healthcare of the Novokuznetsk (rural) district and the territorial medical union of the city of Mezhdurechensk (implementation acts of March 15, 2004, July 18, 2003, and February 29, 2000).

The materials presented in the dissertation are used in the educational process at the Department of Medical Cybernetics and Informatics of the Novokuznetsk State Institute of Advanced Medical Training (implementation act of February 9, 2004).

Methodological recommendations have been prepared and approved by the Department of Health of the Kemerovo Oblast (1999).

A textbook entitled "Formation of Disease Groups for Forecasting and Determining the Population's Need for Various Types of Medical Care" has been published, approved by the Minister of Health of the Republic of Khakassia (2003).

A monograph entitled "Quality of Medical Care and the Role of Heads of Departments of Municipal LHIs in Ensuring It" has been published, edited by Dr. of Medical Sciences, Professor G.I. Chechenin (2003), in which Section 4.3 presents the "Methodology for Determining the Population's Need for Hospitalization and Resource Provision under Conditions of Multilevel Care."

The automated information system "Formation of the Municipal Order for Inpatient Care Taking into Account Multilevel Care Based on Forecasting of Need" (AIS "MO"), developed in co-authorship with G.I. Chechenin, V.A. Yunusova, A.G. Nikitin, and N.M. Zhilina, has been registered in the sectoral fund of algorithms and programs: State registration number in the information and library fund of the Russian Federation 50200300941 (registration date November 20, 2003); State registration number in the national information fund of unpublished documents 50200301101 (registration date December 26, 2003).

Testing of the Work. The results of the conducted studies have been reported at:

- the republican conference "Informatization in the Activities of Medical Services" (Moscow, 1992);

- two conferences with international participation: "Ecology and Public Health of the Population" (Novokuznetsk, 1994) and "Application of Computer Technologies in Medicine" (Izhevsk, 1996);

- the international symposium "Information Databases in Medicine. Monitoring of Population Health and the Environment — 99" (Egypt, Hurghada, 1999);

- four Russian scientific and practical conferences: "MedSocEconInform" (Moscow, 1999); "First Clinical — Healthcare of Russia" (Novokuznetsk, 1999); "System of Automation in Education, Science, and Production" (Novokuznetsk, 2001), and "Information-Analytical Systems and Technologies in Healthcare and OMS" (Krasnoyarsk, 2002);

- two international forums: "Information Technologies and Intellectual Provision in Healthcare and Environmental Protection — 2000" and "Informatization of Population Health Protection Processes — 2001" (Turkey, Kemer, 2000-2001);

- three interregional scientific and practical conferences with international participation: "Medical-Social Service and Rehabilitation of Elderly People and Disabled Persons" (Novokuznetsk, 2002), "State and Main Trends of Population Health of the Regions of Russia at the Beginning of the 21st Century" (Barnaul, 2002), and "Hygiene, Organization of Healthcare, and Occupational Pathology" (Novokuznetsk, 2003);

- the First All-Russian Congress "Profession and Health" (Moscow, 2002);

- as well as at eight regional scientific and practical conferences (Novokuznetsk, 1999-2003, Izhevsk 2001)

- and three scientific and practical conferences (Novokuznetsk, 1993; 1998; Vladivostok, 1995).

The automated system for the management of multilevel medical care delivery to the population was awarded a diploma of second degree at the regional competition "Innovations and Inventions of the Year — 2002."

Publications. Based on the materials of the dissertation, 61 scientific works have been published (including 6 in the central press and 13 in international editions), 2 methodological recommendations have been prepared (with co-authors) and published, a textbook has been published, and a chapter in a monograph has been written.

The author's personal contribution consists in the compilation of the research program, the selection of the object and units of observation, the formulation of tasks, the improvement of informational support for the assessment of population health through participation in the compilation of instructional and methodological materials; the organization and conduct of expert work in the city of Novokuznetsk and the Republic of Khakassia; the preparation of data on population health during the testing of methodological approaches to the assessment of the risk of the occurrence of additional diseases of the population caused by the negative impact of the environment. A methodology for the calculation of correction coefficients for hidden diseases of the population has been developed and scientifically substantiated. Methodological approaches to determining the need for medical care, taking into account the sex-age structure of the population, the forecast of the number of registered diseases, correction coefficients for hidden diseases, and the population risk from the impact of environmental factors, have been developed. The methodology for normalizing the intensity of bed utilization through differentiated reduction of idle time during emergency and planned hospitalization of patients has been adapted. Jointly with specialists of the Cluster Medical Information and Analytical Center (I.V. Kramer, V.A. Yunusova, A.G. Nikitin), an algorithm for the optimization of hospital activity within the framework of the automated system "Municipal Order" has been developed, including taking into account the multilevel nature of medical care delivery.

Main Provisions for Defense:

1. Methodological approaches to determining the population's need for inpatient medical care based on: forecasting of public health indicators, taking into account the sex-age structure of the population, the assessment of societal losses from premature mortality, and the influence of the environment on population health at the place of residence.

2. The level of need for inpatient medical care is determined by negative trends in the sex-age structure of the population, public health indicators, and losses from premature mortality against the background of the unfavorable impact of the environment on population health, which requires its refinement and the improvement of the system of inpatient medical care delivery.

3. Municipal and state orders for inpatient medical care, adequate to the population's need for hospitalization, taking into account the multilevel nature of its delivery, serve as the basis for the real improvement of the population's satisfaction with inpatient medical care and its effectiveness within the framework of the program of state guarantees.

4. The technology for the introduction and organization of a multilevel medical care delivery system within the framework of municipal and state orders under conditions of healthcare reform at the urban and territorial levels, and adequate informational support for the management of inpatient medical care delivery.

Volume and Structure of the Dissertation. The dissertation is set out on 300 pages of typescript and consists of an introduction, an analytical review of the literature, a chapter presenting the program, object, material, and methods of the study, five chapters of original research, conclusions, findings, practical recommendations, a list of references including 298 domestic and 61 foreign sources, 27 appendices, a list of abbreviations used, and is illustrated with 26 figures and 54 tables.