【作者】 李刚；

【导师】 陶红兵；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2017， 博士

【摘要】 [目的]我国医疗资源不足与浪费现象并存,表现为优质医疗资源紧张,住院服务利用低效、过度,同时医保基金的支出增速超出筹资速度,医疗保险基金运行不可持续风险剧增,如何通过评价住院服务适宜性促进医疗资源合理使用成为亟待解决问题。本研究旨在借鉴国内外医院住院日适宜性评价方法及经验,结合我国医疗卫生工作实际,制定无效住院日识别指标体系,对涵盖医院全部医疗流程、医疗费用相对较高的手术科室患者不合理住院时间进行识别,分析国内三级综合医院手术患者无效住院日的现状,并从医方、患方、社会方分析影响无效住院日的因素;进而基于精益管理和不完全信息条件下的博弈理论相关思想,构建无效住院日管理策略概念模型,针对医方、患方和社会方制定不同的管理策略。为医院加强内部管理、卫生行政部门优化医疗资源配置及医保部门加强基金监管等提供理论和实证依据。[方法](1)文献研究:查阅国内外有关住院适宜性评价方面的文献及我国关于住院日管理的相关法律法规和政策文件,为构建无效住院日识别指标体系、建立无效住院日影响因素集及制定无效住院日管理策略提供理论依据。(2)专家咨询:在文献研究的基础上,对国内大型三级综合医院抽25名具有丰富的临床及医疗管理工作的专家进行2轮专家咨询,综合运用德尔菲法和焦点小组访谈,初步建立我国三级综合医院手术患者无效住院日识别指标体系和影响因素集。(3)问卷调查:依据三级综合医院手术患者无效住院日影响因素集,采用Likert 5级标度方法编制调查问卷,了解手术科室的临床医生、护士及医院医疗管理人员对影响因素影响程度的态度。为保证样本医院的同质性和抽样的科学性,本研究充分考虑我国各地区医疗卫生资源分布情况和医疗技术水平差异,根据2014年度东、中、西部地区三级综合医院出院病人总数比例(东:中:西=1.5:1.25:1),采用分层随机抽样的方法,每个地区选取5家三级综合医院,东、中、西部地区各家医院随机选取手术科室临床医生、护士及医院医疗管理人员各60人、50人、40人,合计750人参与调查。(4)因子分析:运用主成分分析法对无效住院日影响因素调查问卷结果进行探索性因子分析,研究三级综合医院手术患者无效住院日影响因素的内在结构,对影响因素重新进行归类。并依据研究结果,制定三级综合医院手术患者无效住院日原因分析表。(5)病例实证研究:采用典型抽样和等距抽样相结合的方法,抽取3个典型手术共408份病历作为样本病例,合计4986个住院日,组织临床、护理专家运用无效住院日识别指标和原因分析表对每一个住院日进行评价,分析三级综合医院手术患者无效住院日现况;结合样本病历病案首页信息和原因分析结果,运用数理统计方法对无效住院日影响因素进行定量分析。[结果](1)建立了符合中国特色的三级综合医院手术患者无效住院日识别指标体系,识别指标体系包括医疗服务、护理/生命支持服务及病人状况三大方面,共19项标准。(2)构建了三级综合医院手术患者无效住院日影响因素集,影响因素主要分为医方因素、患方因素及社会因素三大方面,共21个因素;编制了《三级综合医院手术患者无效住院日影响因素调查表》和《三级综合医院手术患者无效住院日原因分析表》。(3)病例实证研究结果显小,我国三级综合医院中78.43%的手术患者存在无效住院日,无效住院日比例达21.13%。总无效住院日平均为2.58天,其中术前无效住院日平均为1.19天,术后无效住院日平均为1.39天。(4)影响因素定性分析结果显示,因子分析提取医方、患方及社会方3个公因子,其中医方公因子贡献率46.27%,患方公因子贡献率8.96%,社会方公因子贡献率5.33%,累计贡献率达到60.56%。(5)影响因素定量分析结果显示,主要为医方因素和患方因素,不包括社会因素。其中医生保守的病人管理理念,检验检查延误,手术或操作延误及患者或家属要求延长住院时间占比超过90%。(6)患者年龄、入院途径、是或含多个疾病诊断、手术切口等级、术后是否使用呼吸机等均与三级综合医院手术患者无效住院日显著相关。[结论](1)国内尚未建立住院日适宜性评价指标,本研究通过文献分析、专家咨询建立的三级综合医院手术患者无效住院日识别指标体系,广泛适用于所有手术科室,且容易操作,可有效进行无效住院日识别和原因分析。(2)三级综合医院手术患者无效住院情况总体不容乐观,无效住院患者比例高,无效住院日占比较高,一定程度上加重了患者就医负担,造成医疗资源严重浪费,且增加了院内感染等医疗安全隐患。(3)三级综合医院手术患者无效住院日影响因素主要包括医方、患方和社会因素,其中影响最大的为医方因素,其次为患方因素,再次为社会因素。医方因素主要集中在医疗流程不完善、资源配置不足及医生保守的病人管理理念等方面;患方因素主要为要求延长住院时间和拒绝回家或出院;社会方因素主要是经济因素,包括医疗保险报销政策差异等。(4)针对造成无效住院日的影响因素,借鉴精益管理和博弈理论等相关思想,构建无效住院日管理概念模型,针对医方、患方和社会方分别采取不同的管理策略,能够有效减少无效住院日,对促进医疗资源有效利用和医保基金运行安全具有重要意义。(5)从医方层面减少三级综合医院手术患者无效住院日的管理策略主要有引入临床路径管理思维,规范诊疗过程;合理配置并利用医疗资源;以患者为核心,重组医疗服务流程。(6)从患方层面减少三级综合医院手术患者无效住院日的管理策略主要有重视患者教育,加强医患沟通;及时识别特殊身份患者,采取应对措施。(7)从社会层面减少三级综合医院手术患者无效住院日的管理策略主要有改革医保支付制度；完善分级诊疗制度建设。[创新与不足](1)创新之处研究方法上,通过借鉴审核评价(UR)、入院及住院日适当性评价方案(AEP)等国际评价方法和理念,结合国内医疗工作实际,构建了适合国情的三级综合医院手术患者无效住院日识别指标体系和影响因素集,并综合运用定性研究和定量研究方法,对无效住院日影响因素进行分析,填补了国内住院日有效性评价研究的空白,为医疗机构评价住院服务适宜性和改善医疗服务流程提供了理论依据。研究视角上,本研究从医疗服务供需双方及社会方的角度,分析无效住院日的影响闵素,借鉴精益管理和博弈理论等相关思想,构建了三级综合医院手术患者无效住院日管理概念模型,并针对性的提出管理措施。研究视角新颖、切合实际,研究结果对卫生行政部门优化医疗资源配置,医保机构加强医保基金监管及医院探索建立现代医院管理制度等提供决策和支持依据。(2)不足之处由于病例实证研究需要投入大量人力、物力,故抽样对象仅限于湖北省,其研究结论的全国推广还有待进一步验证。更多还原

【Abstract】 [Purpose]The coexistence of the shortage and waste of China’s medical resources was revealed by insufficient high-quality medical resources,excessive use of in-hospital services,as well as the growth of medical insurance fund spending beyond the speed of financing,which indicates the risk of unsustainable operation of medical insurance fund has soared.How to evaluate the rational use of hospital medical resources has become an urgent problem to be solved.This study aims to draw lessons from domestic and foreign assessment methods and experiences of suitability hospitalization days,combined with the actual medical and health work in China to develop identification standards and models of ineffective hospitalization days,identifying unreasonable hospitalization time of surgical patientscovering all the hospital medical procedures whose medical costs are relatively high in order to analyze the status of ineffective hospitalization in the three-level general hospital,and to analyze the factors that affect the ineffective hospitalization day from the aspects of suppliers and demanders of medical services,society and so on;based on Lean Management and Bayesian game theory further,we are to establish a concept model of management strategy of ineffective hospitalization time,and then to provide targeted tacticsrespectively,which provide theoretical and empirical basis to help hospitals strengthen internal management,and to help health administrative departments to optimize the allocation of medical resources and health insurance departments to strengthen the rational use of funds,etc.[Methods](1)Literature research:To access to domestic and foreign literature on the evaluation of hospital suitability,China’s hospital management on the relevant laws and policy documents,and to provide the proof for the construction of ineffective hospitalization date identification criteria and evaluation model,and the establishment of index system of ineffective hospitalization day influence factors.(2)Expert consultation:On the basis of literature research,we selected 25 experts with clinical and mangement experiences from tertiary hospitals for consultation twice,establishing identification standards and index systems of influencing factors of ineffective hospitalization days by using Delphi method and focal group interview comprehensively.(3)Questionnaire:Based on The Index System of Influencing Factors of Ineffective Hospitalization in Tertiary General Hospitals,the questionnaires were prepared according to Likert 5 scale method,aiming to know the attitude of clinical practitioners,nurses and monitors of hospitals to above influencing factors’ effect.In order to ensure the homogeneity of the sample hospitals and the scientificity of the sampling,we have taken full account of the distribution of medical and health resources in various regions of China,according to the total number of discharged patients of tertiary hospitals in the eastern,central and western regions in 2014(East:Central:West=1.5:1.25:1),we used stratified random sampling method to select five tertiary general hospitals from each region,and from each hospital we randomly selected surgical department clinicians,nurses and hospital medical Management of the 60 people,50 people,40 people,a total of 750 people involved in the survey.(4)Factor analysis:The principal component analysis was used to analyze the result of questionnaire survey on influencing factors,and then we reclassified those influencing factors,and further explore the internal structure of the evaluation index of ineffective hospitalization factors,and formulated the table of causes of ineffective hospital days based on the foregoing result.(5)Case retrospective analysis:Three kinds of cases of operation records were taken from the sample hospital by carrying on typical sampling and isometric sampling together,a total of 408 cases were used as samples,which adds up to 4986 days in all.We conducted relevant clinical and nursing experts to use the identification index of ineffective hospitalization date and the cause analysis table to evaluate each hospital day and analyze the status of hospitalization of the three-level general hospital.In the case of the analysis of the information and cause of the patient’s medical record,we ran quantitative analysis of influencing factors of invalid hospitalization day by mathematical statistics method.[Results](1)The identification index system and evaluation model of the inpatient days of the three-level general hospital patients with Chinese characteristics were established。There were 19 criteria for the identification of the index system including three major aspect-medical service,nursing/life support service and patient status.(2)The influencing factors set of ineffective hospitalization days of three-level general hospital patients were established,and the influencing factors were divided into three aspects:medical factors,factors of patient and social factors,a total of 21 factors;we developed The Questionnaire about The Influencing Factors of Ineffective Hospitalization Days of Three-level General Hospital Patients and The Table of Causes of Ineffective Hospital Days.(3)Study on cases showed that there are 78.43%of surgicalpatients in tertiary general hospitals with ineffective hospitalization in China,ineffective hospitalization time accounts for 21.13%of total length of stay.The average length of stay was 3.58 days,of which the average preoperative hospital stay was 1.19 days,the average postoperative hospital stay was 1.39 days.(4)The results of qualitative analysis of influencing factors of ineffective hospitalization days of surgical patients in three-level general hospitals showed that medical factors,factors of patient and social factors were extracted from factor analysis in which medical factors’ contribution rate were 46.27%,contribution rate of factors of patients accounted for 8.86%,and contribution rate of social factors were 5.33%,the cumulative contribution rates were up to 60.56%.(5)The results of quantitative analysis of influencing factors of ineffective hospitalization days of surgical patients in three-level general hospitals showed that medical factors and patient factors are the mainly factors,not including social factors Conservative management concept of doctors,booking or reporting delays,surgical or operational delays,ineffective hospitalization led by patients or their families requiring to extend the hospitalization time,these top five factors accounted for more than 90%cumulatively.(6)The age of the patient,the route of admission,or the presence of multiple diseases,the level of surgical incision,whether or not the use of ventilator after surgery were significantly associated with the ineffective hospitalization of the three-stage general hospital.[Conclusions](1)China has not yet established the hospitalization suitability evaluation index.In this study,we used the literature analysis and expert consultation to establish a invalid hospitalization identification index system and a evaluation model for three-level general hospital surgery patients,which are widely applicable to all surgical departments,and easy to operate.Ineffective date of hospital can be identified,and its causes can be analyzed effectively.(2)The whole situation of ineffective hospitalization of surgical patients in three-level general hospital is not optimistic.The proportion of patients with ineffective hospitalization is high,and the proportion of ineffective hospitalization days is high,too.To some extent,this increases the burden of patients to a certain extent,increasing the medical security risk of cross-infection in hospital,and resulting to severe waste of medical resources.(3)The factors affecting the ineffective hospitalization of the three-level general hospital mainly include the medical,the patient and the social factors,among which the most influential factors are the medical factors,followed by the factors of the patients,and the social factors.Medical factors cover the poor medical procedures,lack of resources,doctors conservative patient management philosophy and so on.Patient factors are that patients requiring extended hospital stay,refusing to go home or to discharge.Social factors are mainly economic factors,including differences in medical insurance claims policy.(4)Aiming at the influencing factors of ineffective hospitalization days,the conceptual model of invalid hospitalization management was constructed based on the related thoughts of lean management and game decision-making.Taking management measures to the doctors,patients and social initiatives to different,can effectively reduce the ineffective hospitalization days,which has important significance for promoting the effective use of medical resources and safeguarding the operation of health insurance fund.(5)From the aspect of hospital,management strategies to reduce the ineffective hospitalization in the three general hospitals are the introduction of clinical path management thinking,standardizing the diagnosis and treatment process;rational allocation and use of medical resources;reorganization of medical service processes concentrated on patients.(6)From the aspect of patient,management strategies to reduce the ineffective hospitalization in the three general hospitals are paying attention to patient education,and strengthening communication between doctors and patients;identification of special status patients to take measures timely.(7)From the aspect of society,management strategies to reduce the ineffective hospitalization in the three general hospitals are medical insurance payment system reform;improving the hierarchical treatment system construction.[Innovations and deficiencies](1)InnovationsIn theory,by using the international evaluation tools such asUR and AEP,combined with the actual domestic medical work,this paper constructs an evaluation standard and model of inpatient suitability suitable for Chinese condition,and establishes a set of ineffective hospitalization evaluation tools suitable for China,which enrich the application of induced demand theory in evaluating the rational utilization of medical resources.Meanwhile,the qualitative research and quantitative research methods were used to analyze the influencing factors of invalid hospitalization days.In perspective,based on the appropriate evaluation of hospitalization services,this project explored the factors influencing the suitability of health services for hospitalization from the perspective of suppliers and demanders of medical services,and hospital managers.The research perspective is novel and realistic,and the research results will provide references for the enrichment of the theory of induced demand,and the improvement of the hospital service quality management and the security payment of medical insurance fund.(2)DeficienciesSubject to the limitations of the objective conditions,the research failed to implement the experimental intervention of ineffective hospitalization days.In addition,because the research object is limited to Hubei Province,the national extension of its conclusions needs to be further verified.更多还原