【作者】 王霞；

【导师】 徐勇勇；

【作者基本信息】 第四军医大学 ， 流行病与卫生统计学， 2001， 硕士

【摘要】 医院提高医疗服务质量，不仅要有宏观政策的正确引导，整体结构的优化，而且质量管理应尽可能深入到医疗活动的各个环节，以便及时发现问题，消除错误及浪费，达到医疗服务质量的持续改进。本研究借助于网络版医院信息系统，采集并分析住院病人住院期间的费用过程信息、诊疗过程信息及辅诊过程信息，目的在于发现医疗服务消费过程中存在的规律与问题，为医疗服务质量的持续性改进提供参考依据。 利用SPSS和SPLM统计软件，分析了260例手术住院病人和572例非手术住院病人在院期间的药品费用过程信息和诊疗过程信息，3427例住院病人的辅诊检查过程信息，具体内容及结果如下： 1．手术病人日药费随住院时间的变化规律 按ICD-9-CM类目表的15个系统大类（解剖学分类）将住院手术病人分为15组，分析了各系统手术病人住院期间日药品费用的变化规律，结果显示：神经系统、肌肉骨骼系统、鼻口咽系统和女性生殖系统手术的日药费中位数线图具有相似的变化规律：手术病人住院期间的日药费 硕士学位论文中位数的峰值位于手术当日，且手术当日的日药费变异最大；术后住院日的日药费中位数明显降低；术前住院日的日药费中位数很低；消化系统和体被系统手术在手术当日及术后1～6天内的日药费中位数维持在较高的水平。各系统手术平均日药费随住院时间变化的规律性，提示手术病人药品费用的控制重点在于围手术期用药。 二．手术病人抗生素应用分析 使用频率最高的药品是调节水、电解质和酸碱平衡类药，占28．8％，其次为抗感染药，占15．3％，第三位是维生素类药品，占9．8％。抗感染类药物中，使用频率最高的药品是抗生素类药品，其使用频次占抗感染类药使用频次的79刀％。各类药品的使用频率基本反映出手术病人的用药原则：补液、抗感染、支持。 260例手术患者中，有63例使用了抗生素类药品，占24，2％，抗生素费用占总药费的34二％。注射用青霉素钠、注射用氨节青霉素钠、注射用头抱哇晰钠的使用频率较高，三项之和占抗生素使用频率的60％以上，为抗感染治疗的主要药物。昂贵类抗生素的使用频率虽然不高 （9石％），但其费用却占有较大的比例（55．2％）。可见，如果昂贵类抗生素使用不合理，必然导致药品费用剧增。预防性使用贵重及昂贵类抗生素比例偏高，用药时间过长，是控制的重点。 3．住院手术病人中无效住院日的存在状况及其影响因素分析 无效住院日在住院手术病人中普遍存在，发生率为64．7％，主要分布在术前lwt天内。逐步回归分析结果显示，影响无效住院日的因素有费别、术前住院日和住院时间。若消除无效住院日，可使手术病人的平均住院日缩短1．5天。 4．非手术住院病人日药品费用的分布及变化规律 80％以上的日药费在100元以下，其药费合计仅占总药费的16．3％。 －互互． 硕士学位论文仅有7．5％的日药费在300元以上，而其费用合计却占总药费的63．7％。日药费随住院时间的变化可归纳为三种类型：日药费变化平缓型、住院中期上升型和出院前期上升型。三种类型在病人中常混合存在。 5．非手术病人出院带药分析 本文对出院带药予以界定。出院带药发生率为50．4％。有出院带药的病人，其平均日药费和平均药费远高于无出院带药的病人。LOgistiC口归分析结果显示，费别因素是出院带药的主要原因，出院带药的控制重点应放在免费、治愈病人上。 6．辅诊检查时效分析 将检查按检查类别进行分类（特检、病理、放射、螺旋CT、磁共振、内窥镜等），检查时间按流程分为申请一预约、预约一检查、检查一报告三段。各类检查从申请到报告所需的时间呈偏态分布，且变异较大，非参检验结果显示，各类检查从申请到报告所需的时间有显著性差异，特检平均所需的时间较长，内窥镜检查平均所需时间最短。各类检查不同环节所需时间有显著性差异，检查到报告之间平均所需时间最短，均在1 小时之内，说明时间的延误可能不在该阶段。特检和放射两类检查从申请到预约、预约到检查之间平均时间较长，其他各类检查从预约到检查段的时间较长。更多还原

【Abstract】 To promote the quality of hospital service, not only proper introduction of macro-policy and optimization of whole structure, but also quality management involved in all kinds of healthcare activities are needed so as to discover problems promptly and to eliminate mistakes and waste. For the purpose of discovering rules and problems existed in the process of consumption of healthcare service, we collected and analyzed the process information of cost, diagnosis and treatment, and diagnostic exams of inpatients during their hospitalization by means of Hospital Information System (HIS, network version). This study can provide foundations for continuous quality improvement of healthcare service.We analyzed the process information of medicine cost and diagnosis and treatment of 260 operation inpatients and 572 non-operation inpatients, and diagnostic exams of 3427 inpatients with SPSS and SPLM software. The contents and results are as follows:1. Regular pattern of daily medicine cost change of operation inpatients during hospitalizationOperation inpatients were divided into 15 groups according to ICD-9-CM. We analyzed the regular pattern of daily medicine cost change of operation inpatients during hospitalization in every group. The results indicated that the median line of daily medicine cost had similar regular pattern in operations on the nervous system, the musculoskeletal system, the nose, mouth, and pharynx system and the female genital organs system : the top of daily medicine cost median emerged on the day of operations; The median of daily medicine cost was low in the period after operation, and the lowest in the period before operation. The median line of daily medicine cost of operations on the digestive system and the integumentary system keeped ata high level in the period of 1-6 days after operations. The regular pattern of daily medicine cost change showed that medicine cost control should be emphasized on the medicine use in perioperative period.2. The analysis of applying antibioticThe most frequently used medicines were those for balancing water, electrolite, acid and alkalescence (28.8%) in the body, and followed by anti-infection (15.3%) and vitamin (9.8%). Of anti-infection medicines, the frequency of antibiotic application was the highest (79.0%). The frequency of the use of these medicines showed the principles of medicine application were fluid infusion, anti-infection and health support.In 260 operation inpatients, there were 63 inpatients applying anti-infection medicine (24.2%). The cost of anti-infection medicine accounted for 34.1% of total medicine costs. The frequency of applying Penicillin, Acillin and Cefamezin was quite high, representing more than 60% of all antibiotics. Obviously, they are the main medicines for infectious diseases. Although the expensive antibiotics were used only in a few inpatients (9.6%), their cost was higher. If expensive antibiotic application is unreasonable, it is certain to result in the rapid increase of medicine cost. The control should be emphasized on the following 2 points: expensive and valuable antibiotics were used too often for prophylactics, and the time of applying them was too long.3. Analysis of the situation and influencing factors of inefficient hospitalization days of operation inpatientsInefficient hospitalization days were prevalent in operation inpatients (incidence rate 64.7%), mainly distributing in the period of 1-4 days before operation. Stepwise regression analysis showed that the influencing factors on inefficient hospitalization days were fee type, hospitalization days before operation and length of stay. If the inefficient hospitalization days had been eliminated, average length of stay would be shortened by about 1.5 days.4. The distribution and regular pattern of daily medicine cost change of non-operation inpatients80% of daily medicine cost were less than 100 yuan, but the sum was just 16.3% of total medicine cost. 7.5% of daily medicine cost were more than 300 yuan, but the sum was 63.更多还原