Evaluation of Continuity of Care: What Can Physician Survey Add?

Background: The evaluation of continuity of care is usually based on the indicators of the frequency of patients' contacts with specific providers. There are some first attempts to use physician survey for the evaluation. Objective: Is to get additional information on the continuity of care in Russia by a newly developed physician questionnaire with detailed questions related to the specific areas of providers' interaction in the health system. Methods: The questionnaire was developed to increase the number of characteristics and indicators for the evaluation of informational, longitudinal and interpersonal continuity. Each of 17 questions was pretested by a group of experts. A small physician survey was conducted through the mobile App with 2690 respondents. A sample is skewed to young and urban respondents. The attempts have been made to increase its representativeness. Results and discussion: We identified the areas of low continuity of care in Russia. Access to electronic medical records is limited. Outpatient and inpatient physicians rarely contact with each other. Primary care physicians are unaware of the substantial part of hospital admissions and emergency visits of their patients, which makes them unprepared for the follow-up treatment. Home visits to patients with heart attack and stroke after hospital discharge are rare. The lack of timely transfer of hospital cases to rehabilitative and social care settings also limits continuity of care. However, a small scale of the survey and its online operation limit its representativeness and robustness. Bigger scale of the survey with the same or similar questionnaire can improve its results. Conclusion: Physician survey can be a useful instrument of care continuity evaluation. The content of the suggested survey can be valuable for collecting the international evidence.

The hard way from the Beveridge to the Bismarck model of health finance: Expectations and reality in Russia.

Most post-Soviet countries have introduced mandatory health insurance (MHI) systems which completely or partially replaced national health systems known as budgetary models. In Russia, an attempt was made to introduce a competitive MHI model with multiple health insurers. The current MHI system has, however, acquired an increasing number of features inherent in the previous budgetary model. This study analyzes the institutional characteristics and the outcomes of a new mixed model. A combination of two analytical approaches is used as follows: (1) considering three functions of the financing system (revenue collection, pooling funds, and purchasing healthcare) and (2) exploring three types of the model regulation (state, societal, and market). We analyze the types of regulation that are used to implement each of the three financial functions. The model has contributed to more sustainable health funding, its geographical equalization, and service delivery restructuring, while the implementation of its purchasing function has many unsolved problems. We highlight the dilemma of the further development of the model by (a) continuing to replace the remaining market and societal regulatory mechanisms with state regulations or (b) developing market mechanisms and thereby strengthening the impact of health insurers on the health system performance. Lessons for countries considering the transformation of their budgetary health finance model to the MHI model are presented.

Structural changes in the Russian health care system: do they match European trends?

ВACKGROUND: In the last two decades, health care systems (HCS) in the European countries have faced global challenges and have undergone structural changes with the focus on early disease prevention, strengthening primary care, changing the role of hospitals, etc. Russia has inherited the Semashko model from the USSR with dominance of inpatient care, and has been looking for the ways to improve the structure of service delivery. This paper compares the complex of structural changes in the Russian and the European HCS. METHODS: We address major developments in four main areas of medical care delivery: preventive activities, primary care, inpatient care, long-term care. Our focus is on the changes in the organizational structure and activities of health care providers, and in their interaction to improve service delivery. To describe the ongoing changes, we use both qualitative characteristics and quantitative indicators. We extracted the relevant data from the national and international databases and reports and calculated secondary estimates. We also used data from our survey of physicians and interviews with top managers in medical care system. RESULTS: The main trends of structural changes in Russia HCS are similar to the changes in most EU countries. The prevention and the early detection of diseases have developed intensively. The reduction in hospital bed capacity and inpatient care utilization has been accompanied by a decrease in the average length of hospital stay. Russia has followed the European trend of service delivery concentration in hospital-physician complexes, while the increase in the average size of hospitals is even more substantial. However, distinctions in health care delivery organization in Russia are still significant. Changes in primary care are much less pronounced, the system remains hospital centered. Russia lags behind the European leaders in terms of horizontal ties between providers. The reasons for inadequate structural changes are rooted in the governance of service delivery. CONCLUSION: The structural transformations must be intensified with the focus on strengthening primary care, further integration of care, and development of new organizational structures that mitigate the dependence on inpatient care.

Vertical program of screenings and check-ups in the Russian Federation: design, implementation and lessons learnt.

BACKGROUND: The Russian Federation has introduced a vertical large-scale program of 'dispensarization' (Program) that includes health check-ups and screenings for the entire adult population. It is expected to improve the results of medical interventions and ensure health gains at a relatively low cost. The major research question: Does the design and implementation of the program meet the expectations? METHODS: We analyze regulatory acts and the literature on the design and the outcomes of the Program. Physicians' surveys and interviews are conducted to understand the capacity of primary care providers to meet the requirements of the Program, as well as the link between the early identification of new illnesses and their follow-up management, administration of the program, the barriers to its successful implementation. RESULTS: There is a substantial progress in the coverage of the population and increase in the number of identified illnesses. Some specific instruments of the Program implementation work well, others require more careful design and additional integrative and managerial activities. The capacity of primary care providers does not allow to provide high quality preventive services, as well as to ensure a continuum of preventive and curative work. The pattern of the Program administration facilitates its nation-wide implementation according to the unified rules, but makes it more difficult to account for the local conditions and limits the autonomy of professionals to choose specific population risk groups and a list of services. The interaction of providers in preventive activities is inadequate. CONCLUSION: The expectations of the Program are too high due to the inconsistencies in its design and implementation. The major lesson learnt is that the program like this should meet the capacity of primary care and be designed as a complex of interrelated activities to identify illnesses and provide their follow-up management.

Understanding the role of physicians within the managerial structure of Russian hospitals.

This article examines the role of physicians within the managerial structure of Russian hospitals. A comparative qualitative methodology with a structured assessment framework is used to conduct case studies that allow for international comparison. The research is exploratory in nature and comprises 63 individual interviews and 49 focus groups with key informants in 15 hospitals, complemented by document analysis. The material was collected between February and April 2017 in five different regions of the Russian Federation. The results reveal three major problems of hospital management in the Russian Federation. First, hospitals exhibit a leaky system of coordination with a lack of structures for horizontal exchange of information within the hospitals (meso-level). Second, at the macro-level, the governance system includes implementation gaps, lacking mechanisms for coordination between hospitals that may reinforce existing inequalities in service provision. Third, there is little evidence of a learning culture, and consequently, a risk that the same mistakes could be made repeatedly. We argue for a new approach to governing hospitals that can guide implementation of structures and processes that allow systematic and coherent coordination within and among Russian hospitals, based on modern approaches to accountability and organisational learning.

Heterogeneous Nuclear Ribonucleoproteins Involved in the Functioning of Telomeres in Malignant Cells.

Heterogeneous nuclear ribonucleoproteins (hnRNPs) are structurally and functionally distinct proteins containing specific domains and motifs that enable the proteins to bind certain nucleotide sequences, particularly those found in human telomeres. In human malignant cells (HMCs), hnRNP-A1-the most studied hnRNP-is an abundant multifunctional protein that interacts with telomeric DNA and affects telomerase function. In addition, it is believed that other hnRNPs in HMCs may also be involved in the maintenance of telomere length. Accordingly, these proteins are considered possible participants in the processes associated with HMC immortalization. In our review, we discuss the results of studies on different hnRNPs that may be crucial to solving molecular oncological problems and relevant to further investigations of these proteins in HMCs.

The evolving Semashko model of primary health care: the case of the Russian Federation.

This paper addresses the major developments in primary care in the Russian Federation under the evolving Semashko model. The overview of the original model and its current version indicates some positive characteristics, including the financial accessibility of care, focus on prevention, patient lists, and gatekeeping by primary-care providers. However, in practice these characteristics do not work according to expectations. The current primary-care system is inefficient and has low quality of care by international standards. The major reasons for the gap between the positive characteristics of the model and the actual developments are discussed, including the excessive specialization of primary care, weak health-workforce policy, the delay in the shift to a general practitioner model, and the dominance of the multispecialty polyclinic, which does not prove advantageous over alternative models. Government attempts to strengthen primary care cover a wide range of activities, but they are not enough to improve the system and cannot do this without more a systematic and consistent approach. The major lesson learnt is that the lack of generalists and coordination cannot be compensated for by the growing number of specialists in the staff of primary-care facilities. Big multispecialty settings (polyclinics in the Russian context) have the potential for more integrated service delivery, but to make it happen, action is needed. Simple decisions, like merging polyclinics, do not help much.

Proteomics of mammalian mitochondria in health and malignancy: From protein identification to function.

The mitochondrial set of proteins is a dynamic system, crucial for multiple functions of this organelle. Differential expression of genes in various tissues, alternative splicing, post-translational modifications, turnover and spatial dynamics of proteins are the factors that influence mitochondrial proteomes increasing their versatility. A wide range of high-throughput proteomic approaches are extensively used for identification, quantification and functional assessment of human and other mammalian mitochondrial proteins. This article reviews the methods and approaches which can be utilized for achieving one or another specific goal in mitochondrial investigations, and the recent advances in application of proteomics to study the roles of mitochondria in tumorigenesis and cancer progression.

Adopting new medical technologies in Russian hospitals: what causes inefficiency? (qualitative study).

The adoption of new medical technologies often generates losses in efficiency associated with the excess or insufficient acquisition of new equipment, an inappropriate choice (in terms of economic and clinical parameters) of medical equipment, and its poor use. Russia is a good example for exploring the problem of the ineffective adoption of new medical technologies due to the massive public investment in new equipment for medical institutions in 2006-2013. This study examines the procurement of new technologies in Russian hospitals to find the main causes of inefficiency. The research strategy was based on in-depth semistructured interviews with representatives of prominent actors (regional health care authorities, hospital executives, senior physicians). The main result is that inefficiencies arise from the contradiction between hospitals' and authorities' motivation for acquiring new technologies: hospitals tend to adopt technologies which bring benefits to their department heads and physicians and minimize maintenance and servicing costs, while the authorities' main concern is the initial cost of the technology.

Cofilin-1 and Other ADF/Cofilin Superfamily Members in Human Malignant Cells.

Identification of actin-depolymerizing factor homology (ADF-H) domains in the structures of several related proteins led first to the formation of the ADF/cofilin family, which then expanded to the ADF/cofilin superfamily. This superfamily includes the well-studied cofilin-1 (Cfl-1) and about a dozen different human proteins that interact directly or indirectly with the actin cytoskeleton, provide its remodeling, and alter cell motility. According to some data, Cfl-1 is contained in various human malignant cells (HMCs) and is involved in the formation of malignant properties, including invasiveness, metastatic potential, and resistance to chemotherapeutic drugs. The presence of other ADF/cofilin superfamily proteins in HMCs and their involvement in the regulation of cell motility were discovered with the use of various OMICS technologies. In our review, we discuss the results of the study of Cfl-1 and other ADF/cofilin superfamily proteins, which may be of interest for solving different problems of molecular oncology, as well as for the prospects of further investigations of these proteins in HMCs.

Study of Splicing Factor, Proline- and Glutamine-rich by Proteomic Techniques in Human Malignant and Nonmalignant Cell Lines.

Splicing factor, proline- and glutamine-rich protein (SFPQ), was identified in eight human cultivated cell lines by proteomic approaches. The cell proteins have been separated by means of two-dimensional gel electrophoresis in two modifications and identified by matrix-assisted laser desorption ionization mass spectrometry with further tandem mass spectrometry. The analysis of proteins from three human sarcomas cell lines (RD, U-2 OS and SK-UT-1B), three human renal adenocarcinomas cell lines (A-498, 769-P and OKP-GS), and two prostate adenocarcinomas cell lines (DU-145 and PC-3) revealed several electrophoretic isoforms of SFPQ protein. Differences between theoretical and experimental molecular masses and isoelectric points of SFPQ protein have been observed. Detailed investigation of SFPQ peptides by tandem mass spectrometry has detected new phosphorylation state of threonine residue in 168 position of SFPQ isoform in rhabdomyosarcoma cell line. Furthermore, SFPQ has not been identified during proteomic study of several nonmalignant cell lines, including cultured human mesenchymal stromal cells and myoblasts. However, SFPQ has been found in all malignant cell lines in high quantity. In particular, its fractions are abundant in sarcomas cell lines as opposed to nonmalignant mesenchymal cells. It is assumed that high quantity of SFPQ in sarcomas cell lines may affect tumorigenesis.

Enzyme immunoassay and proteomic characterization of troponin I as a marker of mammalian muscle compounds in raw meat and some meat products.

The skeletal muscle protein troponin I (TnI) has been characterized as a potential thermally stable and species-specific biomarker of mammalian muscle tissues in raw meat and meat products. This study proposed a technique for the quantification of TnI comprising protein extraction and sandwich enzyme-linked immunosorbent assay (ELISA). The technique is characterized by a TnI detection limit of 4.8 ng/ml with quantifiable concentrations ranging from 8.7 to 52 ng/ml. The method was shown to be suitable for detection of TnI in mammalian (beef, pork, lamb, and horse) meat but not in poultry (chicken, turkey, and duck) meat. In particular, the TnI content in beef was 0.40 3 ± 0.058 mg/g of wet tissue. The TnI estimations obtained for the pork and beef samples using ELISA were comparable to the proteomic analysis results. Thus, the quantitative study of TnI can be a convenient way to assess the mammalian muscle tissue content of various meat products.

Alcohol consumption, drinking patterns, and cognitive function in older Eastern European adults.

OBJECTIVE: To investigate associations of frequency, quantity, binge, and problem drinking with cognitive function in older Eastern European adults. METHODS: The investigation included 14,575 participants, aged 47 to 78 years at cognitive assessment in 2006-2008 from Novosibirsk (Russia), Krakow (Poland), and 6 Czech towns participating in the HAPIEE (Health, Alcohol, and Psychosocial Factors in Eastern Europe) prospective cohort study. Average response rates were 59% at baseline (2002-2005) and 63% in 2006-2008. Alcohol consumption was assessed at baseline and in 2006-2008. Cognitive tests included immediate and delayed word recall, semantic fluency (animal naming), and letter cancellation. Associations between alcohol indices and cognitive scores were analyzed cross-sectionally (all measures from 2006 to 2008) and prospectively (alcohol and covariates from 2002 to 2005 and cognition from 2006 to 2008). RESULTS: In cross-sectional analyses, nondrinkers had lower cognitive scores and female moderate drinkers had better cognitive performance than light drinkers. Heavy, binge, and problem drinking were not consistently associated with cognitive function. Few associations were replicated in prospective analyses. Participants who stopped drinking during follow-up had worse cognition than stable drinkers; in men, regression coefficients (95% confidence interval) ranged from -0.26 (-0.36, -0.16) for immediate recall to -0.14 (-0.24, -0.04) for fluency. CONCLUSION: Regular and episodic heavy drinking were not consistently associated with cognitive function. Worse cognition in participants who stopped drinking during follow-up suggests that inclusion of less healthy ex-drinkers may partly explain poorer cognition in nondrinkers.

An assessment of progress towards universal health coverage in Brazil, Russia, India, China, and South Africa (BRICS).

Brazil, Russia, India, China, and South Africa (BRICS) represent almost half the world's population, and all five national governments recently committed to work nationally, regionally, and globally to ensure that universal health coverage (UHC) is achieved. This analysis reviews national efforts to achieve UHC. With a broad range of health indicators, life expectancy (ranging from 53 years to 73 years), and mortality rate in children younger than 5 years (ranging from 10·3 to 44·6 deaths per 1000 livebirths), a review of progress in each of the BRICS countries shows that each has some way to go before achieving UHC. The BRICS countries show substantial, and often similar, challenges in moving towards UHC. On the basis of a review of each country, the most pressing problems are: raising insufficient public spending; stewarding mixed private and public health systems; ensuring equity; meeting the demands for more human resources; managing changing demographics and disease burdens; and addressing the social determinants of health. Increases in public funding can be used to show how BRICS health ministries could accelerate progress to achieve UHC. Although all the BRICS countries have devoted increased resources to health, the biggest increase has been in China, which was probably facilitated by China's rapid economic growth. However, the BRICS country with the second highest economic growth, India, has had the least improvement in public funding for health. Future research to understand such different levels of prioritisation of the health sector in these countries could be useful. Similarly, the role of strategic purchasing in working with powerful private sectors, the effect of federal structures, and the implications of investment in primary health care as a foundation for UHC could be explored. These issues could serve as the basis on which BRICS countries focus their efforts to share ideas and strategies.

Opportunities and limitations of patient choice: the case of the Russian Federation.

While many countries have increased the opportunities for patient choice of provider, there is debate to what extent this has had positive effects on efficiency and quality of healthcare provision. First, some conditions should be met to exercise such choice, of which the most important is the provision of reliable data on providers' performance to both patients and physicians as their agents, as well as increasing primary health care (PHC) providers' involvement in realization of patient choice. Second, expanding patient choice does not always lead to efficient allocation of resources in a healthcare system. This article explores these controversial developments by using empirical evidence from the Russian Federation. It shows that choice indeed has value for patients, but there are many areas of inefficient choice, which leads to misallocation of healthcare recourses. Thus, health policy in this area should be designed to ensure a reasonable balance between objectives of expanding choice and promoting more efficient organization of healthcare provision. Political rhetoric about unlimited patient choice may be useless and even risky unless supported by well-balanced programmes of supporting and managing choice.

Health and health systems in the Commonwealth of Independent States.

The countries of the Commonwealth of Independent States differ substantially in their post-Soviet economic development but face many of the same challenges to health and health systems. Life expectancies dropped steeply in the 1990s, and several countries have yet to recover the levels noted before the dissolution of the Soviet Union. Cardiovascular disease is a much bigger killer in the Commonwealth of Independent States than in western Europe because of hazardous alcohol consumption and high smoking rates in men, the breakdown of social safety nets, rising social inequality, and inadequate health services. These former Soviet countries have embarked on reforms to their health systems, often aiming to strengthen primary care, scale back hospital capacities, reform mechanisms for paying providers and pooling funds, and address the overall shortage of public funding for health. However, major challenges remain, such as frequent private out-of-pocket payments for health care and underdeveloped systems for improvement of quality of care.

A review of health financing reforms in the Republic of Moldova

In the context of global efforts to move towards universal coverage in health systems, this report reviews health financing reforms in the Republic of Moldova and looks in particular at how the population ́s access to health services has been affected. In 2004, as has been widely documented elsewhere, wholesale reforms were made to the way in which government funds were used to fund health services, shifting the system overnight from a highly fragmented and inflexible one, to one in which funds for the health sector were pooled nationally, allowing improved risk-sharing as a result of greater flexibility to allocate funds in line with health needs. A new source of funding in the form of a payroll tax for health was also introduced directly leading to a growth in total levels of government health spending. A second phase of reforms starting in 2009 addressed the issue of gaps in population coverage under mandatory health insurance, with legislative measures taken to ensure that all citizens of Moldova had access to primary health care, and to ensure that the poor receive subsidized health insurance. Fiscal constraints have limited the full implementation of these reforms however.Moldova has shown that it is prepared to tackle difficult policy issues head on and has articulated clear goals for the sector. In particular, the Roadmap “Accelerating Reforms: addressing the needs of the health area through investment policies” approved on 1 March 2012, lays a clear agenda for the next phase or priority reforms focusing on principally on service delivery reorganization but also on health financing. This is the correct focus given that progress on a number of priority indicators such as equity in access to services and financial protection has been limited in recent years. This report summarizes the main impact of health financing reforms to date and agrees with the Roadmap about the major challenges for the coming decade, in particular the need to address inefficiencies in service delivery, but also to ensure that the close link between guaranteed benefits and available funding is maintained in future policy decisions.

Russian Federation. Health system review.

The HiT reviews are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. At independence from the Soviet Union in 1991, the Russian health system inherited an extensive, centralized Semashko system, but was quick to reform health financing by adopting a mandatory health insurance (MHI) model in 1993. MHI was introduced in order to open up an earmarked stream of funding for health care in the face of severe fiscal constraints. While the health system has evolved and changed significantly since the early 1990 s, the legacy of having been a highly centralized system focused on universal access to basic care remains. High energy prices on world markets have ensured greater macroeconomic stability, a budget surplus and improvements in living standards for most of the Russian population. However, despite an overall reduction in the poverty rate, there is a marked urban rural split and rural populations have worse health and poorer access to health services than urban populations. The increase in budgetary resources available to policy-makers have led to a number of recent federal-level health programmes that have focused on the delivery of services and increasing funding for priority areas including primary care provision in rural areas. Nevertheless, public health spending in the Russian Federation remains relatively low given the resources available. However, it is also clear that, even with the current level of financing, the performance of the health system could be improved. Provider payment mechanisms are the main obstacle to improving technical efficiency in the Russian health system, as most budget funding channelled through local government is input based. For this reason, the most recent reforms as well as legislation in the pipeline seek to ensure all health care funding is channelled through a strengthened MHI system with contracts for provider payments being made using output-based measures.

Russian Federation: health system review

The HiT reviews are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. At independence from the Soviet Union in 1991, the Russian health system inherited an extensive, centralized Semashko system, but was quick to reform health financing by adopting a mandatory health insurance (MHI) model in 1993. While the health system has evolved significantly since the early 1990s, the legacy of a highly centralized system focused on universal access to basic care remains. High energy prices on world markets have ensured greater macroeconomic stability, a budget surplus and improvements in living standards for most of the Russian population. However, there is a marked urban–rural split and rural populations have worse health and poorer access to health services than urban populations. Provider payment mechanisms are the main obstacle to improving technical efficiency in the Russian health system, as most budget funding channelled through local government is input based. The most recent reforms as well as legislation in the pipeline seek to ensure all health care funding is channelled through a strengthened MHI system with contracts for provider payments being made using output-based measures.