Improvement of Outpatient-Polyclinic Care in the General Practice Model

The dissertation is devoted to the improvement of outpatient-polyclinic care in the general practice model. The research analyzes the current state of the healthcare system, identifies deficiencies in the organization of medical care and problems in the treatment of statistically significant groups of diseases, in particular diseases of the respiratory organs. On the basis of socio-hygienic, clinical-experimental, and statistical research, the necessity of developing new medical-organizational technologies is justified. A structural-functional model of outpatient-polyclinic care based on new technologies was created and implemented in the work, including programs for training physicians, diagnostic algorithms and prevention programs, and methods for monitoring quality. Special attention is given to the development of new approaches to the treatment of bronchitis and pneumonia, such as combined therapy, ultraviolet hemotherapy, and laser-antibiotic activation. The practical significance consists in improving the quality of examination, diagnosis, and treatment, reducing the level of morbidity, and improving health indicators of the population.

Relevance of the Problem

Health indicators of the Russian population and unfavorable demographic trends in recent years indicate a clear deterioration: the country's population has decreased by 0.7–0.9 million; the birth rate is one of the lowest in the world at 10.3 per 1,000 inhabitants (2003; in the Russian Federation, the uniquely low birth rate was 1,267 thousand persons, i.e., 8.7 per 1,000 inhabitants); the mortality rate is one of the highest in Europe at 16.5 per 1,000 inhabitants. Depopulation, as a dramatic demographic phenomenon, gave rise to the image of the "Russian cross." Since 1991, depopulation in Russia has been intensifying, and the gap between mortality and birth rate indicators reached an unprecedented magnitude: −6, −5 (Lisitsyn Yu.P., 2002). The principal health indicator—life expectancy of less than 65 years—ranked 102nd in the world (2000), compared to 35th place in 1975. According to the United Nations classification, a population is considered aging if the proportion of persons over 65 years of age exceeds 7%; at present, this indicator in Russia is 12.5%. In Russia, more than 60% of patients in polyclinic consultations are persons over 60 years of age (Lisitsyn Yu.P., 2002; Weber V.R., 2005).

For the development of scientifically grounded therapeutic and preventive measures aimed at improving socio-demographic indicators, population health, and reducing morbidity, great interest, in the opinion of Denisov I.N., Shchepin O.P., and Weber V.R. (2004, 2005), is presented by the study and development of more advanced medical-organizational technologies.

Existing organizational forms, models, and methods of outpatient-polyclinic care are currently far from perfection and cannot be used in the healthcare system due to their low efficiency (Denisov I.N., 1999, 2000; Lisitsyn Yu.P., Shchepin V.O., Vyalkov A.I., 2004; Denisov I.N., 2005; Chernienko E.I., 2005; Zurabov M.Yu., 2005).

At the same time, a rapid increase in the number of functional disorders and diseases, including chronic ones, and the "chronicization" of acute conditions is noted. More than 60% of the population has chronic diseases; among adolescents alone, according to 34 diseases, on average 27% of them have 5 or more chronic diseases, and by 2000 this indicator reached 1000‰. Only from 1995 to 2000, the absolute increase in chronic diseases amounted to 670‰, corresponding to a growth rate of +23.5%. A large group of these is represented by diseases of the respiratory organs (Sukhareva L.M., Lisitsyn Yu.P., 2002; Bezrukhov M.M., 2004; Lisitsa D.N., 2005), which occupy the third rank among causes of mortality and the first to third places in the structure of primary morbidity (Lisitsyn Yu.P., 2002).

The rational organization of treatment and prevention of diseases, including those of infectious-inflammatory etiology, whose frequency in outpatient-polyclinic practice fluctuates, according to various authors, from 10% to 35%, despite the permanent introduction of new antibacterial agents into clinical medicine (Men'shikov D.D., 2004; Vasina T.A., 2005). The questions of selecting effective agents and methods that allow targeted influence on the stimulation of regulatory functions of the organism and the management of pharmacological characteristics of antibacterial preparations remain unresolved (Men'shikov D.D., 2005; Vasina T.A., 2005).

The many years of experience of our work and the literature data indicate the necessity of developing new organizational forms and models of therapeutic and preventive measures for the sick and the healthy, which will make it possible to achieve an improvement in outpatient-polyclinic care (Denisov I.N., 2000, 2005; Khalfin R.A., Chernienko E.I., 2004, 2005; Starodubov V.I., Shchepin O.P., Ovcharov V.K., 2005).

The above convinces us of the necessity of improving medical-organizational technologies in the system of primary health care (Chernienko E.I., Lisitsyn Yu.P., Starodubov V.I., 2003; Denisov I.N., Shchepin V.O., 2004, 2005), which determined the necessity of carrying out the present work.

Research Objective

Improvement of population health through the development and justification of a comprehensive approach to the improvement of outpatient-polyclinic care, treatment, and prevention of diseases affecting morbidity indicators.

Research Tasks

1. Conduct an analysis of the state of health of the population in the investigated territories with an evaluation of the quality of outpatient-polyclinic care, identifying factors that exert an influence on medical-demographic indicators and morbidity indicators. Analyze the causes of diseases of the respiratory organs as one of the statistically significant groups in the structure of overall morbidity.

2. Scientifically justify and develop a complex of medical-organizational technologies aimed at improving primary health care.

4. Create and implement a structural-functional model of outpatient-polyclinic care based on the experience of international and Russian projects and own developments.

5. Carry out an organizational experiment on the basis of polyclinics with different forms of ownership and demonstrate the effectiveness of new organizational forms of outpatient-polyclinic care.

6. Develop new technologies that improve the quality of functioning of the structural-functional model.

7. On experimentally modeled infectious-inflammatory processes, study the influence of new technologies in the treatment of diseases of the respiratory organs.

8. Develop new and improve existing methods of quantum therapy that increase the antimicrobial activity of biological fluids; study their safety and effectiveness in complex therapy of infectious-inflammatory processes.

9. Develop new methodological approaches that expand the possibilities of prevention and treatment of bronchitis and pneumonia in outpatient conditions.

10. Evaluate the role of new medical-organizational technologies in general practice.

Scientific Novelty of the Research

For the first time, a comprehensive socio-hygienic in-depth analysis of the organization of medical care in outpatient-polyclinic institutions of different forms of ownership was conducted, identifying factors that exert an influence on morbidity indicators and population health and developing mathematical models determining the strength of these factors.

The technology for the improvement of outpatient-polyclinic care was scientifically justified on the basis of the results of the conducted organizational experiment: a new universal structural-functional model was developed that makes it possible to improve the quality of work of general practices.

The following were introduced into practice within the developed universal structural-functional model: a) methods and a program for training general practitioners; b) diagnostic algorithms and prevention programs; c) regulations, instructions, and medical-statistical documentation; d) new technologies in treatment; e) criteria for evaluating activity, quality indicators, and effectiveness of therapeutic and preventive care.

For the first time, a comparative expert evaluation of the activity of general practices was provided in the organizational experiment on the model implemented in the system of outpatient-polyclinic care in healthcare institutions of different forms of ownership.

An automated expert-analytical monitoring system with a patient database and modules of specialized systems was created and implemented. Their role in improving the quality of work of general practices was scientifically justified.

For the first time, relying on the data of experimental studies conducted "in vitro" and "in vivo," as well as on extensive clinical material with paraclinical methods of research, a strategy and tactics for the treatment of acute and chronic bronchitis and pneumonia in general practice were developed, based on the combined use of antibacterial preparations with physical and physico-chemical factors of influence.

New methods of prevention and treatment of bronchitis and pneumonia and their complications were proposed, and paths for their prevention were outlined. In a comparative study in the experiment of antibiotics of various chemical groups (penicillins, cephalosporins, and aminoglycosides), their action on various links of the immune system was established, explaining the influence of antibiotic therapy on the state of immune reactivity.

An increase in the antibacterial activity of the biosubstrate during the conduct of quantum therapy was established.

On the basis of the conducted research and evaluation of treatment effectiveness, optimized methods of antibacterial therapy with physico-chemical methods of influence were developed for patients with acute and chronic bronchitis and pneumonia.

Practical Significance

The in-depth socio-hygienic research of existing models of general practice made it possible to identify the most optimal, from organizational and clinical positions, medical-organizational technologies.

The developed structural-functional model of general practice may be recommended for use in practical healthcare for the improvement of outpatient-polyclinic care.

Unified criteria for evaluating the activity of general practitioners/family practitioners allow, in dynamics, to correct indicators of patient and family health, as well as to determine the effectiveness of specific health-improving measures, taking into account that final results depend largely on certain material and technical and staffing conditions, the corresponding medical and organizational technology, and the level of information support.

The implementation in healthcare institutions, including medical centers, of the expert-analytical monitoring system and medical-statistical documentation gave general practitioners the opportunity to improve the operativity, quality, and effectiveness of the diagnostic-therapeutic process and to create conditions for a more rapid recovery of patients.

Diagnostic algorithms in the practice of general practitioners in the new model ensure a high degree of reliability of the clinical diagnosis.

Risk factor identification and prevention programs improve the quality of life of patients, preventing the development of severe diseases at early stages and are available for use in the direction of work of general practitioners — health preservation of healthy individuals.

New methods of quantum antibiotic therapy in the complex treatment of bronchitis and pneumonia in outpatient conditions ensure early recovery.

The developed treatment regimens possess a pronounced prolonged and synergistic antibacterial action, significantly reduce the frequency of complications of diseases in the treatment of bronchitis and pneumonia, and are indicated for patients with associated chronic diseases.

The application of quantum antibiotic therapy led to a reduction in mortality by 1.8–2.1 times in the treatment of acute pneumonias and complications of infectious-inflammatory diseases.

The new structural-functional model of general practice introduced into the practice of outpatient-polyclinic institutions of Moscow led to an improvement in the quality of examination, diagnosis, treatment, and rehabilitation of the attached contingent, identification of risk factors with subsequent conduct of targeted preventive measures.

Principal Propositions to Be Defended

1. High morbidity indicators and loss of capacity for work are caused by deficiencies in the organization of outpatient-polyclinic care and a shortage of new technologies.

2. The implementation of a rationally scientifically justified organizational model of general practice led to the optimization of medical care at the outpatient-polyclinic stage, a reduction in population morbidity indicators, and a shortening of the duration of treatment of patients.

3. The use of new medical-organizational forms of work in general practice: a new methodology and training program, systematic use of basic classical approaches in outpatient-polyclinic practice, the application of monitoring for the optimization of work, and the resolution of medico-social problems led to a reduction in the morbidity level of the attached contingent, and most significantly in the system of non-state healthcare.

4. New possibilities of combined therapy and prevention of diseases in the activity of general practitioners/family practitioners: non-drug influences (quantum therapy), as one of the components, exerting a significant influence on the increase in diseases of the respiratory organs.

5. The improvement of the etiotropic therapy effectiveness in outpatient-polyclinic practice among patients with bronchitis and pneumonia can be ensured by the application of a tactic of differentiated conduct of combined quantum therapy. The results of the work were implemented into practice.

Implementation of the Results of the Work into Practice

The principal propositions of the dissertation were adopted as the basis for the organization of the general practice service in Family Clinic No. 4, Polyclinic No. 66 and No. 88 of Moscow, and the polyclinic of the Administration of the President of the Russian Federation. The results of the research are used in the training of senior students and residents at RUDN, MMA named after I.M. Sechenov, in cycles of postgraduate education of physicians at RMANPO, and the Educational and Scientific Medical Center of the Administration of the President of the Russian Federation. Seven educational publications with the stamp of the Methodological Association of Universities of Russia, including the results of dissertation research, have been published.

The principal bases for the practical use of the provisions of the dissertation are outpatient-polyclinic institutions of Moscow.

The developed monitoring system is applied in the organization of primary health care in the work of general practitioners/family practitioners in outpatient-polyclinic institutions of Moscow, the Moscow Region, and the Russian Federation. Certificate of the Ministry of Health of the Russian Federation No. 243 dated 22.10.2002.

The materials were presented at the II All-Russian Congress of General (Family) Practitioners of the Russian Federation. Cheboksary, 2004.

The materials of the research were reported at the scientific-practical conference of Polyclinic No. 88 of Moscow "Main Stages in the Development of Polyclinic Care." Moscow, 2005.

The materials of the research were reported at the scientific-practical conference "Scientific-Practical Work of Physicians of the Polyclinic over 5 Years (2000–2005)." Family Clinic No. 4. Moscow, 2005.

The materials of the research were reported at the scientific-practical conference on questions of dispensaryization. Polyclinic of the Administration of the President of the Russian Federation "Questions of Organization and Conduct of Dispensaryization of the Attached Contingent in the Conditions of a Polyclinic." Moscow, 2006.

The materials of the research were reported at the scientific-practical conference of physicians "Modern Methods of Diagnosis and Treatment in the Conditions of a Polyclinic." Polyclinic No. 66 of Moscow, 2006.

On the topic of the dissertation, 52 printed works have been published, including 6 monographs.

Volume and Structure of the Dissertation

The dissertation is presented on 318 pages of typed text; consists of an introduction, a review of literature, a characterization of the material and methods of research, four chapters of own research, a conclusion, conclusions, and practical recommendations. The work is illustrated by 35 tables, 25 figures, 18 schemes, and other materials (in appendices). The bibliographic reference includes 490 sources, of which 316 are in Russian and 174 in foreign languages.