四病种实施临床路径改革效果研究

发布时间：2018-08-09 12:52

【摘要】：2012年开始,为贯彻落实《中共中央国务院关于深化医药卫生体制改革的指导意见》、《关于公立医院改革试点指导意见》、《临床路径管理试点工作方案》等文件精神,响应国家开展临床路径的号召,规范临床诊疗行为,提高医疗质量,保障医疗安全,国家卫计委卫生发展研究中心开展了"一体化诊疗路径与支付方式改革实践与传播项目"(以下简称"项目"),以探索通过临床路径和支付方式改革相结合的公立医院改革新模式。目的:对项目实施效果进行评价。通过收集临床路径干预前后医院四个慢性病病种(脑出血、脑梗死、短暂性脑缺血、慢性阻塞性肺炎)患者的相关信息资料,研究和评价临床路径和支付方式改革的效果。内容:主要包括研究实施临床路径和采取总额预付、单病种付费支付方式改革前后患者费用、住院日、医师诊疗行为规范、患者生命质量和满意度变化情况等内容。方法：选择项目试点医院中某一家三级综合医院,收集2012年7月至2015年5月期间脑出血、脑梗死、短暂性脑缺血和慢性阻塞性肺炎四个慢性病病种出院患者的信息,主要包括病案首页、患者日清单以及EQ-5D调查量表。以2013年11月为项目干预点,运用间断性时间序列方法对病案首页中的患者数据进行分析,主要包含两个部分,第一部分内容为分析患者费用变化情况,主要包含患者住院总费用、药费、自付、检查费、护理费等;第二个部分分析患者住院日变化情况。通过分析日清单,对照临床路径表单内容,分析项目实施之后医师诊疗规范情况。通过对住院患者发放和回收EQ-5D量表,分析出院患者在项目实施前后生命质量改善情况。对以上定量资料分析采用描述性统计分析,单因素统计分析。另外还通过文献分析法搜寻文献,为本文内容奠定基础;通过访谈法了解医院医务人员对实施临床路径的态度和建议,并整理成文字,作为后期结论的支撑。主要结果:(1)项目实施后对患者医疗费用起到了一定的控制作用,抑制了费用过快增长。(2)项目实施对有效缩短住院日起到了积极作用。(3)临床路径表单中部分诊疗项目的实施情况得以改善,医师诊疗行为规范化。(4)项目实施对提高患者健康水平,改善患者生命质量情况具有积极作用。临床路径在控制费用不合理增长、缩短住院日和规范医师诊疗方面作用显著,值得肯定和推广,为了更好的和成功开展临床路径,结合项目试点医院经验,提出以下建议:(1)政府和医院领导重视,是顺利开展临床路径的前提。(2)结合支付方式改革,充分、全面考虑人的因素,是临床路径成功与否的关键。(3)配备相关硬件设备、提高信息化建设是实施临床路径的基础。(4)建立科学的监管机制是临床路径有效实施的保障。(5)多渠道宣传是拓展临床路径广泛应用的有效途径。
[Abstract]:Since 2012, in order to implement the spirit of the "guiding opinions of the CPC Central Committee and the State Council on deepening the Reform of the Medical and Health system", the "pilot guidance opinions on the Reform of Public Hospitals" and the "pilot Program of Clinical Pathway Management", Responding to the call of the state to develop clinical pathways, standardize clinical diagnosis and treatment behavior, improve medical quality, and ensure medical safety, The Health Development Research Center of the State Health and Family Planning Commission has carried out the "practice and Communication Project of Integrated diagnosis and treatment path and payment Reform" (hereinafter referred to as "Project") in order to explore a new mode of public hospital reform through the combination of clinical pathway and payment mode reform. Objective: to evaluate the effect of project implementation. To study and evaluate the effect of the reform of clinical pathway and payment method by collecting the relevant information of four kinds of chronic diseases (cerebral hemorrhage cerebral infarction transient cerebral ischemia and chronic obstructive pneumonia) before and after the intervention of clinical pathway. Content: the main contents include the implementation of clinical pathway and the adoption of total advance payment, single disease payment before and after the reform of patient costs, hospitalization days, physician diagnosis and treatment behavior norms, patients' quality of life and satisfaction changes and so on. Methods: one of the three level general hospitals in the pilot hospital was selected to collect the information of four kinds of chronic diseases, such as cerebral hemorrhage, cerebral infarction, transient cerebral ischemia and chronic obstructive pneumonia, from July 2012 to May 2015. It mainly includes the first page of the medical record, the daily list of patients and the EQ-5D questionnaire. Taking November 2013 as the intervention point of the project, this paper uses intermittent time series method to analyze the patient data in the first page of the medical record, which consists of two parts. The first part is to analyze the changes of patients' costs. It mainly includes the total cost of hospitalization, drug fee, self-payment, examination fee, nursing fee and so on. The second part analyzes the change of patient's day in hospital. By analyzing the daily list and contrasting the contents of the clinical path form, we analyzed the physician diagnosis and treatment standard after the implementation of the project. The quality of life (QOL) of discharged patients was analyzed before and after the implementation of the project by issuing and retrieving the EQ-5D scale. Descriptive statistical analysis and single factor statistical analysis were used to analyze the above quantitative data. In addition through literature analysis to search the literature for the content of this paper lay a foundation; through interviews to understand the hospital medical personnel to implement the clinical path of the attitude and advice and arranged into words as the support of the later conclusions. The main results are as follows: (1) after the implementation of the project, it has played a certain role in controlling the medical expenses of patients. (2) the implementation of the project has played a positive role in effectively shortening the hospitalization days. (3) the implementation of some items in the clinical path form has been improved, and the behavior of physicians in diagnosis and treatment has been standardized. (4) the implementation of the project has improved the health level of patients. Improving the quality of life of patients has a positive effect. The clinical pathway plays a significant role in controlling the unreasonable increase of the cost, shortening the hospitalization days and standardizing the doctor's diagnosis and treatment. In order to develop the clinical pathway better and successfully, we should combine the experience of the pilot hospital with the project. The following suggestions are put forward: (1) the attention of the government and hospital leaders is the prerequisite for the smooth development of the clinical pathway. (2) the key to the success of the clinical pathway is to fully consider the human factors and fully consider the human factors in combination with the reform of the payment mode. (3) the key to the success of the clinical pathway is to equip the relevant hardware equipment. (4) establishing scientific supervision mechanism is the guarantee of effective implementation of clinical pathway. (5) Multi-channel propaganda is an effective way to expand the wide application of clinical pathway.
【学位授予单位】：南京中医药大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R197.1

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