1. Introduction

The problems of ensuring and assessing the quality of medical care are among the most important for any healthcare system. The introduction of new medical technologies and forms of labor organization should be aimed, first of all, at improving quality. The relevance of quality assurance issues increases even more during the period of healthcare reform in the Republic of Uzbekistan, and this explains the need for future doctors to master the concepts of quality, forms and methods of its assessment, methods of quality management and etc.

The problem of the quality and effectiveness of medical care today occupies a priority place in a large number of problems in our healthcare system. Reform of the health care system and, first of all, overcoming acute structural imbalances, combined with the search for intra-system sources of saving money and resources, should in no case affect the quality and accessibility of medical care for the general public.

The transition from the state medical care system to the health insurance system in our country is being carried out in extremely difficult economic and social conditions. According to the modern concept of social protection, the main volume of medical care is provided to the population free of charge under the State Guarantees Program. Medical insurance programs determine the list of types of medical care provided to insured citizens, the conditions for its provision and the required quality.

In the ongoing process of healthcare reform, the problem of ensuring the safety and appropriate quality of medical care in conditions of severe resource shortages is becoming extremely important. It includes the need to solve two main problems: determining the most appropriate combination of various types of medical care for the population and ensuring the proper quality of this care.

Purpose of the study: Identification of factors influencing the quality of medical care in primary care, identification of leading diseases in primary care, study of shortcomings in the examination and treatment of patients.

2. Materials and Research Methods

At the present stage, the most pressing health problem is the problem of adapting the organization of medical care to the population to market conditions. However, the state must not only guarantee the provision of medical care, but also improve the quality of medical services. The therapeutic service plays a major role in the organization of outpatient care. According to the literature, 40-50% of all outpatients are therapeutic patients, and 90% are patients observed by doctors at home.

The quality of therapeutic care for the adult population was studied on the basis of 5 city clinics (numbers 1, 2, 4, 5, 6) in the city of Bukhara, Republic of Uzbekistan. In order to collect statistical data, we developed: “Map of expert assessment of the quality of therapeutic care in clinics”, questionnaires to study the opinions of the population and medical workers about the organization and quality of medical care.

Experts assessed 1040 completed treatment cases. 657 patients of city clinics were examined. The study showed that in the first place are diseases of the respiratory system (31.4%), in second place - the circulatory system (20.6%), in third place - the digestive system (13.2%). Almost the same proportions are urinary (10.4%) and diseases of the musculoskeletal system (9.5%), etc.

Expert assessments have revealed many shortcomings in the examination and treatment of patients. On average, for all diseases, 2/3 (66.9%) of patients were examined in a timely manner, and in 68.2% of cases – incompletely. The percentage of patients who are not fully examined is especially high who had coronary heart disease, pyelonephritis, bronchitis and bronchial asthma (72.9-83.7%).

In 46.2% of cases, the reasons for a complete examination were the lack of diagnostic equipment and facilities, in 19.7% - overload of laboratory diagnostic services, in 12.7% - insufficient qualifications of the attending physician, in 8.6% - the lack of relevant specialists. 7.2% of patients have a specific course of laboratory and diagnostic services, diseases and other reasons - 5.6%.

Timely and correct diagnosis is one of the most important indicators of the quality of medical care. In 8.3% of cases, there was a discrepancy between the diagnoses of the attending physicians and specialists in expert assessment of the quality of diagnosis.

According to experts, 22.4% of patients did not receive adequate treatment (the severity of the patient’s condition was not taken into account, the drugs and their dosage were not selected sufficiently, the course of treatment was not followed, the date of drug withdrawal was not indicated). indicated, etc.). These factors occurred in patients with hypertension (32.9%), bronchial asthma (27.9%), rheumatism (25.0%) and nephritis (24.4%). According to experts, on average, in 5.8% of cases, overtreatment of all diseases was observed, especially peptic ulcer (7.8%), gastritis (7.7%) and cholecystitis (7.3%).

According to experts, in 27.3% of cases the reasons for insufficient treatment are erroneous and not diagnosed on time, in 23.6% - insufficient control over the treatment process by the heads of departments, in 18.2% - indiscipline of patients, in 14.7% - lack of necessary medications, in 10.4% - due to the specific course, diseases and other reasons - 5.8%.

The timeliness and validity of expert recommendations, as well as the quality of the consultative examination, are of little importance in improving the quality of medical care provided to patients. In 19.5% of cases it was found that the appointment of a consultation by the attending physician was timely, and in 17.3% of cases it was unfounded.

According to experts, in 25% of cases, advisory examinations are incomplete, in particular, objective data are not sufficiently described, patients are given incomplete recommendations, treatment is not monitored, etc. On average, 28.0% of free patients needed additional consultation, especially for bronchial asthma (43.3%) and arterial hypertension (36.7%). In 66.3% of cases, there were deficiencies in keeping records of patients in outpatient clinics.

In 18.4% of patients, the duration of treatment was insufficient, and in 12.6%, it was assessed that the duration of treatment was excessive. An analysis of disease outcomes showed that timely and complete treatment led to an improvement in the condition of patients in 16.8% of cases compared with the complete absence of treatment. (x2 = 56.45; p < 0.001). In cases under the supervision of heads of therapeutic departments, treatment resulted in improvement of the patients' condition and recovery in 11.4% of cases compared to uncontrolled cases (x2 = 25.99; p < 0.001).

It is known that one of the criteria for the quality of medical care is its accessibility. To evaluate it, we identified such characteristics as the time a patient waits for a doctor, the ability to freely communicate with his attending physician and doctors of a specific specialty.

A study of the time patients visited the clinic (according to the survey) showed that 36.8% of visitors spent up to 1 hour, 43.7% - up to 2 hours and 19.5% - more than 2 hours.

One of the factors influencing the quality of medical care is the medical activity of the population, in particular, self-assessment of health and timely seeking medical help.

Conducted sociological surveys showed that the majority of respondents (57.2%) assess their health as satisfactory. There were more people who rated their health as poor (21.6%) than those who rated it as average (16.5%). The assessment of the health status of men was higher than that of women: 60.2% of men rated it as satisfactory (women - 55.1%), 16.9% of men rated it as bad (women - 24.9%).

It was found that 72.8% of respondents did not always go to the clinic in the event of an outbreak or outbreak of the disease. They gave the following reasons: they are self-medicating (48.5% of respondents), they hope that the disease will go away on its own (42.6%), they have been waiting for a long time to be examined by a doctor (36.2%), they are at home and busy at work (15.8%), they are not sure that the results of treatment will be good (12.7%).

A study of doctors’ opinions about the organization and quality of medical care showed that more than 2/3 of them found it difficult to answer the question of what components the quality of medical care includes. Only 5.2% of doctors were able to determine the quality of medical care and name its components (sufficiency, efficiency, economic efficiency and scientific and technical level).

3. Results and Discussion

In accordance with the objectives of the study, the opinion of medical specialists about the importance of the influence of various factors on the quality of medical care in clinics was studied. According to the survey results, first place is occupied by the provision of clinics with modern medical equipment (93.8 out of 100 responses), followed by the qualifications of medical personnel (85.4), material incentives for work (78.3), and rational organization of labor, work (58), regular monitoring by department heads (43.7), increasing wages for medical workers (38.4), introducing new diagnostic and treatment methods (25.7), improving staff training (18.3), medical activity population (10.2) and other organizational activities (3.6 per 100 respondents).

The criteria for assessing the quality of medical care were:

• accessibility of medical care - the ability to receive the necessary medical care in the required time frame;

• adequacy of medical care - compliance of the medical care provided to the patient with modern standards;

• continuity of medical care - coordination in medical care provided to the patient at different times, by different specialists and medical institutions;

• effectiveness of medical care - compliance of the medical care provided with the tasks that were assigned to it;

• efficiency of medical care - achieving the planned results of medical care with minimal costs, effort and expenses;

• patient-centeredness - participation of the patient and his relatives in the decision-making process related to his health, as well as satisfaction with medical care;

• safety of the treatment process - guarantees of safety and absence of harmful effects on the patient in a medical institution;

• timeliness of medical care - provision of medical care when the patient needs it.

Monitoring of activities to control the quality of medical care is an analytical system for tracking activities to continuously improve the availability and quality of medical care, the components of which are: continuous observation, analysis, evaluation and forecasting of the results of activities to control and supervise the quality of medical care. Monitoring is aimed at obtaining information about the state and dynamics of the level of quality of medical care, activities for its continuous improvement, studying the level and trends in the development of the quality of medical care system, identifying “critical points” of its functioning, identifying natural dependencies, as well as assessing the direct impact of this area of activity on the quality of medical care.

4. Conclusions

All employees must understand the dependence of quality not only on the activities of an individual, but also on their joint activities, since the patient evaluates quality as a complex of services. In fact, we consider the process as a complex and often interdisciplinary set of activities, as a result of which a certain result is achieved. Applying this insight to health care delivery, we link changes in process to improved outcomes, as well as to the roles of health care stakeholders in that change.