【作者】 陈俊；

【导师】 王天朝；

【作者基本信息】 昆明医学院 ， 社会医学与卫生事业管理， 2010， 硕士

【摘要】 目的:通过对云南省第一人民医院5类单病种住院患者实施临床路径管理前后的队列研究,分析各单个病种的费用构成的变化和产生变化的原因、以及各个影响因素间的相互作用,评价、探讨实施临床路径管理对医疗费用的影响,以期为临床路径管理在控制医疗费用方面找到合适的切入点,在我国现行体制下对实施临床路径管理提供一定的依据,同时也为医保部门在制定单病种费用标准时提供可资借鉴的理论和实践依据。方法:收集云南省第一人民医院在2009年8月1日～2010年2月29日期间诊断标准和治疗方案一致、治疗方案较单纯、病例数相对较多的5个病种纳入本研究,包括子宫肌瘤、良性前列腺增生症、单纯性胆囊结石、结节性甲状腺肿、产科自然分娩,所有病例均为住院治疗病例。采用历史对照队列研究方法,选择在2009年8月1日～2010年1月31日期间住院治疗并实临床路径管理模式的患者为实验组;为了避免或减少物价和医疗技术变化可能对结果产生的影响,选择在同一年住院患者为对照组,即选择在2009年1月1日～2009年7月31日期间入住本院未实施临床路径的相同病种、与实验组患者基本资料具有可比性的患者为对照组。研究资料来源于医院病案资料,主要内容包括:姓名、性别、民族、年龄、疾病名称、疾病分型、入院时情况、医保状况、住院天数、住院总费用、药费、检查费、治疗费、手术费、化验费和疾病转归等资料。比较指标为:姓名、性别、民族、年龄、疾病名称、入院时情况、医保状况、住院总费、药费、检查费、治疗费、手术费、化验费、其他费用(包括护理费,吸氧等)和疾病转归;评价指标为:住院总费用、药费、检查费、治疗费、手术费、化验费、药费占住院总费用的构成比。采用频率对计数资料进行统计描述,假设检验采用卡方检验或Fisher精确概率法;采用均数描述计量资料,统计推断采用t检验或非参数检验。所有统计分析使用SPSS11.5软件包,双侧检验的检验水准定为α=0.05。结果:本研究选择了在2009年8月1日～2010年2月29日期间住院治疗并实施临床路径管理的5个病种的患者作为实验组共237例;选择在2009年1月1日～2009年7月31日期间入住同一医院未实施临床路径的对应5个病种的患者为对照组共249例。两组患者在性别、年龄、入院情况、病例分型、医保状况和转归等方面的差异没有统计学意义(P＞0.05)。平均住院总费用比较得出子宫肌瘤、结节性甲状腺肿、自然分娩3个病种实验组较对照组有所降低,其中结节性甲状腺肿平均住院费用降幅最大,实验组平均住院费用(7820.6元)比对照组(8781.1元)降低了960.53元(P=0.00);良性前列腺增生、单纯性胆囊炎2个病种的平均住院总费用实验组较对照组有所升高,良性前列腺增生症患者的平均住院费用实验组(12806.6元)比对照组(11871.5元)升高了935.04元(P=0.03);单纯性胆囊炎患者实验组(7900.6元)比对照组(7441.4元)增加了459.28元(P=0.19)。5个病种的实验组患者平均住院日较对照组都有不同程度的减少,子宫肌瘤实验组(8.08天)比对照组(10.38天)平均住院日降低了2.30天(P=0.00)。自然分娩、子宫肌瘤、结节性甲状腺肿的实验组平均药费都有降低,结节性甲状腺肿患者药费由对照组的(3434.1元)较实验组的(2201.1元)降低了(P=0.00)。从患者住院的检查费用来看,除了良性前列腺增生实验组(952.9元)费用较对照组(751.3元)增加了(P=0.005),其余4个病种两组之间没有统计学差异性。子宫肌瘤、结节性甲状腺肿2个病种平均治疗费用实验组与对照组比较有统计学差异性,子宫肌瘤患者的平均治疗费实验组比对照组要少,降低了124.6元(P=0.003);结节性甲状腺肿患者住院平均治疗费实验组较对照组升高了162.90元(P=0.00)。5个病种的平均手术费用比较情况来看,实验组与对照组没有太大的变化。从住院总费用的各个构成部分的比较来看,5个病种的对实验组住院总费用影响最大的是平均住院天数和平均药品费用。平均住院天数是影响住院费用很重要的因素,也是控制效果最明显的因素。住院日的缩短,不仅直接导致床位费减少,也造成了医疗资源的节约,导致住院费用降低。药品的控制则是当前的难题,也是医改的难点所在,就我院此次试点结果来看,临床路径在制定时还要进一步规范药品的使用。结论:本次评价的5个病种实施临床路径管理可以降低子宫肌瘤、结节性甲状腺肿、自然分娩患者的平均住院费用;可以缩短的患者平均住院日;实施临床路径管理自然分娩、子宫肌瘤、结节性甲状腺肿3个病种患者的平均药费有所降低;同时子宫肌瘤、结节性甲状腺肿2个病种患者的治疗费用减少;路径管理对手术费用影响不大;表明临床路径管理模式在单病种费用管理中具有减少医疗资源的浪费和控制医疗费用的过快增长的作用。更多还原

【Abstract】 Objective:Five selected diseases were compared and analyzed in terms of medical expense structure,the cause of expense deviation,and the relationship among various causes before and after implementing clinical pathway in First People’s Hospital of Yunnan Province.It was discussed of the impact on medical expense after implementing clinical pathway and hopeful to find solutions on health expenditure control,and to provide evidence based data for health bureau and insurance management in monopathy.Methods:237 inpatients of 5 selected diseases with the same standards of diagnosis,same therapy,enough sample size,and comparable features among groups were chosen in First People’s Hospital of Yunnan Province between August 1,2009 to January 31,2010.The control study of patients with uterine fibroids,benign prostatic hyperplasia,gallbladder stone,nodular enlarged thyroid,natural childbirth were managed as a trial group under clinical pathway between August 1,2009 to February29,2010 and the patients with same diseases and comparable features were managed as a control group without clinical pathway between January 1,2009 to July 31,2010.The selected data includes patient name,gender,nationality,age,disease type,admission conditions,medical insurance coverage,length of stay,hospital charges,drug fees,examination fees,clinical treatment fees,operation fees,laboratory fees and disease condition change,etc.The comparing indicators were patient name, gender,nationality,age,disease types,admission conditions,medical insurance coverage,total hospital charges,drug fees,examination charges,treatment fees, operation fees,laboratory fees and disease outcome.It is evaluated for hospital costs, drugs fees,hospitalization cost,drug expense,examination fees,treatment fees, operation fees,laboratory fees,constituent ratio of the cost of total expense,were defined as the evaluating outcomes indexes.Numeration data were described as frequency and hypothesis test were performed with x~2 test or Fisher’s exact probability;the measurement data were described as mean and standard deviation, and statistical inferences were conducted with T test or Non-parametric test.All statistical methods were performed with SPSS version 11.5 and the two-side significant test level was set up asα=0.05.Results:237 patients of 5 diseases as trial group under clinical pathway were randomly selected between August 1,2009 to February29,2010 and 249 patients with same diseases were put in the control group between January 1,2009 to July 31,2010. There is no statistically difference with gender,age,situation on admission,types of diseases,medical insurance coverage,recovery condition among groups (P＞0.05).Comparing to control group,the total expense of 3 diseases in trail group, such as uterine fibroids,nodular enlarged thyroid and natural childbirth decreased to different extend while the cost of hospitalization didn’t decrease obviously.The total expense of nodular enlarged thyroid patients in trial group with clinical pathway were lower than that of the patients in control group(7820.6yuanVS8781.1yuan,P=0.00), the average total expense decrease 960.53 yuan.Benign prostatic hyperplasia, gallbladder stone in trial group were higher than the patients in control group.The total average expense in the benign prostatic hyperplasia group of the trial group was higher than that of control group(12806.6yuanVS11871.5yuan,P=0.03),with the average total expense increasing 960.53 yuan.The total average expense in the gallbladder stone group of the trial group was higher than that of control group (7900.6 yuanVS7441.4yuan,P=0.19),with the average total expense increasing 459.28 yuan.The average hospital days of 5 diseases were shorter than that of the patients in control group,the average hospital days of uterine fibroids(8.08VS.10.38,P=0.00). The average drug expenditure of natural childbirth,uterine fibroids,nodular enlarged thyroid patients in trial group was statistically difference from that of the patients in control group nodular enlarged thyriod(2201.1yuanVS3434.1yuan).and the examination expense of benign prostatic hyperplasia in trial group were higher than that in control group(952.9yuan vs 201.55yuan),there is no statistical difference of other factors among groups.The average treatment expense of uterine fibroids, nodular enlarged thyroid between groups had statistically difference,uterine fibroids decreased 124.6 yuan(p=0.003) nodular enlarged thyroid decreased 162.90 yuan(p=0.00) relatively.The average operation expense of 5 diseases did not-change obviously between two groups.The average drug expense and the average hospital days were the most important in the constituent ratio of the all expense.The average hospital days is the most important factor to affect hospital expense,it was also the most obvious effect of the factors to be controlled.The shorter length of stay,not only directly leads to reduced bed costs,but also results in savings of medical resources, resulting in lower hospital costs.Appropriate drug usage is the same critical issue as well as health care reform.The data from the research shows that it requires further regulation in drug usage when implementing clinical pathway.Conclusions:The results after implementing clinical pathway for five diseases Showed that the average medical cost can be reduced.It can also cut the average length of stay in controlled group.The average drug expense of natural childbirth,uterine fibroids, nodular enlarged thyroid patients were decreased with clinical pathways.While the cost of treatment of uterine fibroids,nodular enlarged thyroid patients were reduced. Clinical pathway has little effect on in reducing operation costs.It showed that the clinical pathway Plays an important role in the reduction of waste of medical resources and control the excessive growth of medical expenses.更多还原