Scientific Justification for the Optimization of Ophthalmological Care for the Child Population (On the Example of KGUZ "Krasnoyarsk Regional Ophthalmological Children's Hospital")

The dissertation is devoted to the scientific substantiation of the optimization of ophthalmological care for the child population, using the example of KGUZ "Krasnoyarsk Regional Ophthalmological Children's Hospital." The study covers the socio-hygienic aspects of eye morbidity among children, an analysis of the organization of ophthalmological care, and an examination of factors influencing the progression rate of myopia in children. The work is based on materials from Krasnoyarsk region for the years 2000-2005 and includes a comprehensive analysis of patient attendance, hospitalization, and dynamic observation of children with eye diseases. During the study, social factors determining eye morbidity of the child population were identified, methodologies for assessing the effectiveness of outpatient-clinic and inpatient care were developed, and measures for improving the system of ophthalmological services for children in the region were proposed.

Relevance of the study. The socio-hygienic significance of the problem of preserving the health of the child population of the country, with a high level of prevalence of eye pathology (Yu.F. Maychuk, 2000; I.V. Mial'chko, 2004; E.E. Somov, 1945; S.F. Sinyapko, 1999; V.K. Yur'ev, 1995), a trend toward an increase in the population of children with hereditary and congenital pathology of the visual organ, exacerbating ecological problems, an increase in the number of viral immune diseases, intoxication of pregnant women, as well as eye damage in premature infants (M.V. Kutnetsova, 2004; E.S. Libman, E.V. Shakhova, 2005; T.N. Lopatina, 2003; S.A. Gets, 2003; N.I. Pospelov, 2003). Medical measures aimed at reducing infant mortality have simultaneously led to an increase in the number of children with severe perinatal pathology (O.V. Shraer, 2006; A.M. Revta, 2005; N.I. Lyumtyu, 1995). Rising educational visual loads contribute to an increase in the proportion of children with myopia (E.E. Vadas, 2004; A.V. Ermolaev, 2005). The complex socio-economic and demographic situation in the country, the successes of modern medicine in the care of premature children, and the intensity of the educational process in schools impose heightened requirements on the organization of ophthalmological care for children.

Notwithstanding this, the state of children's ophthalmology and the prospects for the development of ophthalmological care for the child population have been addressed by a number of domestic and foreign authors (V.V. Kovshinko, 1995; S.A. Il'ichev, 2003; V.I. Pospelov et al., 1998; 2003; E.E. Somov, N.V. Fomina, 1995; A.V. Khvatova, 2005).

In the mid-1980s, in Krasnoyarsk region, a large-scale study of the dynamics of eye disease morbidity of the population of Krasnoyarsk region was conducted by Professor P.G. Makarov under the methodological guidance of the N.L. Semashko Research Institute of Social Psychiatry and Health Care Organization (I.D. Bogatyrev), with the consultative assistance of the Helmholtz Research Institute of Eye Diseases (A.V. Rosmin, K.V. Trutnev, E.S. Avetisov) and Professor M.A. Dmitriev of KrasSMU. The results obtained made it possible to determine normative standards of the need for ophthalmologists.

In the 1980s, against the background of the growth of material well-being in health care and the adoption of new microsurgical technology, and following the decisions of the country's leadership on the gradual transition of health care to the provision of care based on medical indications through annual dispensarization, it became possible to propose new forms of the organization of ophthalmological care for the population. The priority shifted from a simple redistribution of forces and resources to a more complex task — the redistribution of available resources in accordance with new diagnostic and treatment technology, and the structure and level of morbidity (G. Makarov, 1986).

In Krasnoyarsk region, with the participation of the Helmholtz Research Institute of Microsurgery (S.N. Fedorov) and the Eye Department of TsEMIN (I.S. Libman), new organizational forms of ophthalmological care were developed and implemented: group hospitalization for acute diseases, mega-dispensarization of comprehensive regional hospitals, polyclinic-inpatient care, and the creation of a new type of medical institution — the inter-regional center of eye microsurgery. In November 1972, the Krasnoyarsk Regional Ophthalmological Children's Hospital with 100 beds was opened — the largest specialized ophthalmological children's treatment institution in Russia at that time. Since 1987, the hospital was assigned the functions of an ophthalmic microsurgical children's center (KrasMODT), which could provide therapeutic and consultative care to children in Krasnoyarsk region. For further adjustment of the activities of the regional ophthalmological service, the study of trends in changes in visual acuity indicators, predisposing factors and blindness, and the types of prevalent eye diseases among the population of Krasnoyarsk region, S.F. Sinyapko (1999) essentially repeated the study conducted thirty years earlier.

However, to the present day, the problem of preserving vision remains highly relevant. According to the Inter-district Ophthalmological Bureau of the Krasnoyarsk Region Ministry of Health (T.I. Lopatina et al., 2003), the main causes of disability among children are severe amblyopia of various origins (23.9%), complicated by multiple degree (20.6%), congenital pathology (16.1%), and consequences of injuries (7.6%). Many aspects relating to the health of the population remain uninvestigated. The socio-hygienic factors, the established demographic situation and its impact on eye morbidity of the child population, and the structure of patients receiving treatment in ophthalmological children's departments of the region have also not been studied. When conducting scientific research and making management decisions, the resource of information and computer technologies is insufficiently utilized. The prevention of eye diseases and the optimization of ophthalmological outpatient-clinic and inpatient care for the child population, despite significant achievements in this area, require improvement and increased effectiveness. A socio-hygienic study of eye morbidity among the child population from the standpoint of a comprehensive approach is necessary to inform the scientific substantiation of a system of measures for the optimization of ophthalmological care for children.

The relevance of the topic and its scientific and practical significance logically determined the object, subject, goal, and tasks of the study.

Object of the study: the child population and the ophthalmological service of Krasnoyarsk region.

Subject of the study: socio-hygienic and clinical characteristics of children with diseases of the visual organ, and questions of the organization of ophthalmological care for the child population. The unit of observation is a child who has applied to the KCODB.

Goal of the study: to develop scientifically substantiated measures for the optimization of ophthalmological care for the child population based on a comprehensive analysis of children's eye morbidity (on the example of KGUZ "Krasnoyarsk Regional Ophthalmological Children's Hospital").

Tasks of the study:

1. To conduct an analysis of eye morbidity of the child population of Krasnoyarsk region, identify its features, as well as factors influencing its formation.

2. To study the organization of ophthalmological care for the child population at KGUZ "KCODB": to analyze patient attendance, the level of hospitalization and dynamics by type of settlement and district, the composition of referrals and hospitalizations, the relative intensity of dynamic observation in the outpatient clinic, and the intensity of hospitalizations in the inpatient department.

3. To develop an analytical block for an automated workplace of an ophthalmologist, to be used for studying the progression rate of myopia in children and identifying its features.

4. To develop scientifically substantiated measures for improving ophthalmological care for the child population of Krasnoyarsk region.

Scientific novelty of the study. For the first time, an analysis of eye morbidity and patient attendance of the child population of Krasnoyarsk region was conducted, taking into account the influence of the age structure of the child population and the availability of ophthalmologists.

The following methodologies were developed: assessment of the relative intensity of dynamic observation of children in the outpatient clinic, assessment of seasonal patient attendance, allowing for the optimization of outpatient-clinic care for children with eye diseases; as well as the analysis of repeated hospitalizations of children for the optimization of inpatient ophthalmological care for the child population.

Social factors influencing the progression rate of myopia were identified: age, sex, seasonality of the observation period, average monthly duration of daylight, intensity of the educational process, and the degree of myopia.

The reliability of the research results was ensured by the significant volume of collected materials (over 30 thousand units of observation), the study of the general population of children with eye diseases who applied to the KCODB, a special study of the population of children with myopia (253 children, 452 observation periods), adequate methods of statistical data processing using the licensed package Statistica for Windows for scientific statistical analysis, Microsoft Excel, and the application of the expert assessment method.

Practical significance. The results of the study formed the basis for improving ophthalmological care for the child population of the region and for developing a complex of preventive measures for preserving children's vision: they made it possible to identify risk groups of children for the occurrence of eye diseases depending on age and type of settlement, and to identify organizational factors influencing the level of overall and primary eye morbidity. The proposed method for assessing the intensity of the educational process based on the progression rate of myopia served as the basis for developing preventive measures aimed at reducing childhood myopia morbidity, including recommendations for inter-age and seasonal adjustment of the intensity of the educational process in schools.

The results of the study were implemented at the KCODB and used for improving the provision of ophthalmological care for children in the city of Krasnoyarsk and Krasnoyarsk region (implementation act dated December 1, 2005). The scientific materials are used in the educational process for resident physicians of health care in the postgraduate education system of the Kemerovo State Medical Academy (implementation act dated February 25, 2004), and at the departments of Krasnoyarsk State Medical Academy (implementation act dated September 4, 2006, implementation act dated September 11, 2006).

Positions put forward for the degree:

1. The age structure, availability of ophthalmologists, type of settlement, and accessibility of ophthalmological care have a significant impact on indicators of eye morbidity of the child population.

2. Taking into account the seasonality of referrals and hospitalizations, the relative intensity of dynamic observation in the outpatient clinic, the level of primary hospitalization, the frequency of repeated hospitalizations, the duration of inter-hospital observation and diagnostic examination periods, creates a scientific basis for improving the organization of outpatient-clinic and inpatient ophthalmological care for the child population.

3. When assessing the progression rate of myopia in children, age, sex, type of settlement of the child, seasonality of the observation period, intensity of the educational process, and the degree of myopia should be taken into account.

Presentations of the work. The official positions of the dissertation were reported and discussed at the Inter-regional Scientific and Practical Conference "Modern Medical Technologies in Ophthalmology — An Effective Path to Improving the Quality of Medical Care: Solutions and Problems" (February 24-27, 2004, Kemerovo); the V International Scientific and Practical Conference "Health and Education in the 21st Century" (October 21-25, 2004, Moscow); the International Congress "Health, Learning, and Upbringing of Children and Youth in the 21st Century" (May 12-14, 2004, Moscow); the XI Russian-Japanese International Symposium on Medical Exchange "Medical Exchange" (September 21-23, 2005, Krasnoyarsk); the Regional Scientific and Practical Conference "Current Issues of Primary Medical and Social Care of the Population" (December 23, 2005, Krasnoyarsk); at sessions of the scientific research society and conferences of the ophthalmologists' association of Krasnoyarsk region, 1998-2005; at sessions of the problem commission on public health and health care of the Krasnoyarsk Medical Academy (February 13, 2003, November 9, 2005).

References. Based on the research materials, 14 works have been published, of which 9 in central press, one — in a publication recommended by the VAK for the publication of dissertation results.

A certificate of official registration of the computer program "Automated Workplace of an Ophthalmologist. Analysis Block" was issued by the Federal Service for Intellectual Property, Patents and Trademarks (K 20046] J 063, dated June 11, 2004).

Author's personal contribution. All scientific results presented in the work were obtained, processed, and analyzed personally by the author. The research program and plan were developed, a patent and information search was conducted, and a review of domestic and foreign literature was performed. A material collection map and an expert assessment map were developed. All children with myopia (253 children) were examined and observed personally by the author (452 observation periods). Copying of data into outpatient and inpatient patient cards and other primary medical documents, as well as expert surveys, were carried out. Statistical processing, analysis, and interpretation of the research results were conducted. Recommendations for the optimization of ophthalmological care for the child population were developed. Training seminars were conducted for various categories of medical workers and educators. Implementation of the research results into the educational process and the practical activities of health care institutions was carried out.

The work was carried out at the State Educational Institution of Higher Professional Education "Krasnoyarsk State Medical Academy of Roszdrav" at the Department of Public Health and Health Care within the framework of the regional program "Protection of Vision of the Population of Krasnoyarsk Region."

The author thanks Doctor of Medical Sciences, Professor V.I. Pospelov, the Chief Physician of the KCODB G.K. Smertnaya, and Candidate of Medical Sciences I.S. Orekhova for their understanding, support, and assistance in the organization of the research.

Structure of the dissertation. The dissertation consists of an introduction, five chapters, a conclusion, findings and practical recommendations, a list of references, and an appendix. The main text of the dissertation comprises 151 pages. The work is illustrated with 25 tables, 4 diagrams, and 22 figures. The list of references includes 191 sources, including 37 foreign authors.