【作者】 董波；

【导师】 石东风；

【作者基本信息】 吉林大学 ， 公共卫生硕士（专业学位）， 2017， 硕士

【摘要】 目的:本研究通过对齐齐哈尔地区5家三甲医院泌尿外科实施临床路径的前列腺增生患者进行研究,观察这些研究对象的住院期间总费用、住院时长、术前准备时间、治疗费用、药品费用、辅助检查费用。同时通过组织调查问卷的方式对实施临床路径的医务人员进行临床路径的效果落实评价,组织患者通过调查问卷的方式进行住院患者满意度调查。从而对临床路径的质量进行评估,以希望为有关部门提供重要的科学参考依据,同时通过探索临床路径而为医改提供合理化建议。方法:收集2015年1月至2015年12月期间于齐齐哈尔市5家综合性三甲医院泌尿外科进行就诊并且实施临床路径管理的前列腺增生疾病患者100例,作为路径组。同时选择2014年1月至2014年12月期间5家综合性三甲医院泌尿外科未实施临床路径管理的前列腺增生患者100例作为对照。全部200例患者均行手术治疗,手术方式为经尿道前列腺电切手术。通过医院病历系统分别获得患者的住院期间总费用、平均住院时间、术前准备时间、治疗费用、药品费用、辅助检查费用等。采用调查问卷的方式进行满意度调查及临床路径的认知情况。使用SPSS19.0统计软件进行分析,计量资料之间的比较使用t检验,计数资料之间的差异使用卡方检验进行比较,p<0.05表示差异具有统计学意义。结果:1、路径组100例患者的年龄在45-70岁之间,平均年龄为(58.68±8.25)岁。对照组100例患者的年龄为48-67岁之间,平均年龄为(59.22±7.96)岁。路径组与对照组患者在平均年龄之间的差异无显著性(t=0.471,P=0.638)。两组患者在文化程度之间的差异无显著性(x~2=0.558,p=0.906)。两组患者在在前列腺体积之间的差异无显著性(t=1.398,p=0.164)。两组患者在手术时间上的差异无显著性(t=1.382,p=0.169)。2、路径组患者有5人出现并发症,95人无并发症。对照组有4人出现并发症,96人无并发症。路径组与对照组患者术后并发症的发生率之间的差异无显著性(p=1.000)。3、路径组患者住院期间总住院费用(1.45±0.18)万元,对照组患者住院期间总住院费用(1.61±0.22)万元,路径组患者的总住院费用与对照组患者的总住院费用之间的差异具有显著性,路径组患者明显低于对照组患者(t=5.629,p=0.000)。4、路径组患者平均住院时间为(9.38±1.73)天,对照组患者平均住院时间为(10.56±2.35)天。路径组患者与对照组患者平均住院时间之间的差异具有统计学意义,路径组患者平均住院时间低于对照组患者平均住院时间(t=4.044,p=0.000)。5、路径组患者术前准备时间为(1.27±0.38)天,对照组患者术前准备时间为(1.73±056)天。路径组患者与对照组患者术前准备时间之间的差异具有统计学意义,路径组患者术前准备时间低于对照组患者平均住院时间(t=6.797,p=0.000)。6、路径组患者药品费用为(0.418±0.109)万元,对照组患者药品费用为(0.497±0.136)万元,路径组患者药品费用与对照组患者药品费用之间的差异具有统计学意义,路径组患者药品费用低于对照组患者药品费用(t=4.533,p=0.000)。7、路径组患者辅助检查费用为(0.331±0.085)万元,对照组患者辅助检查费用为(0.379±0.112)万元,路径组患者辅助检查费用与对照组患者辅助检查费用之间的差异具有统计学意义,路径组患者辅助检查费用低于对照组患者辅助检查费用(t=3.414,p=0.001)。8、路径组患者抗生素药品费用为(0.086±0.015)万元,对照组患者抗生素药品费用为(0.093±0.027)万元,路径组患者抗生素药品费用与对照组患者抗生素药品费用之间的差异具有统计学意义,路径组患者抗生素药品费用低于对照组患者抗生素药品费用(t=2.266,p=0.025)。9、路径组患者中有98人对于医疗过程满意,2人对于医疗过程不满意。对照组患者中87人对于医疗过程满意,13人对于医疗过程不满意。路径组患者与对照组患者对于医疗满意率之间的差异具有统计学意义,路径组患者对于医疗满意率高于对照组患者(x~2=8.721,p=0.003)。10、进入临床路径的路径组患者,共有26例出现变异,变异的发生原因包括有医护人员的原因(4例)、患者的原因(11例)、医院的原因(3例)及病情的变化原因(8例)。11、50名医务人员中对于临床路径政策的了解认知情况中有41人完全答对4道题目,有5人答对了3题,有4人答对了2题。12、(1)50名医务人员中有38人觉得医院非常重视临床路径工作,有6人觉得比较重视临床路径工作,有4人觉得对于临床路径的重视程度一般,有2人觉得医院不重视临床路径工作。(2)50人中有42人认为医院政策解读方面开展了临床路径的工作、50人中有39人认为医院组织相关人员调研并制定实施方案、50人中有43人认为医院组织医护人员进行相关培训、50人中有35人认为医院建立了监督机制与惩罚措施、37人认为医院将临床路径的管理工作纳入绩效考核中。(3)50名医务人员中有38人认为自己对临床路径的有关内容掌握的十分清楚,有8人认为自己对临床路径的有关内容掌握的比较清楚,有3人认为自己对临床路径的有关内容掌握的一般了解,有1人认为自己对于临床路径的有关内容不了解。13、(1)50人中有35人认为临床实施阶段最重要;11人认为评价改进阶段最重要;4人认为制定阶段最重要。(2)50人中有35人认为“临床路径管理”和“单病种收费”是不同概念,结合制约;11人认为是不同概念,相互制约;4人认为是同一概念,两种表述。(3)50人中有43人认为常见病、多发病、费用多、手术或处置方式差异小、诊断明确、需住院治疗的病型适用于临床路径管理。有7人认为单纯普通型适用于临床路径管理。(4)50人中有38人认为优化流程,加快诊治效率是促使纳入临床路径管理的因素;有7人认为加强医务人员工作能力,提升技术水平使促使纳入临床路径管理的因素;有5人认为加快床位周转,提升医院经济效益是促使将病人纳入临床路径管理的因素。(5)50人中有46人认为在医院及科室中有必要开展临床路径;有4人认为没有必要开展临床路径。(6)50人中有47人认为临床路径的开展能够获得成功;有3人认为临床路径的开展应该以未来开展情况来定。(7)50人中有36人认为医院管理者管理理念是开展临床路径面对的最大挑战;有9人认为医务人员观念是开展临床路径面对的最大挑战;有5人认为医院现行的事后付费方式是开展临床路径面对的最大挑战。(8)50人中有48人认为通过临床路径进行“标准化”能够达到地域间的协同医疗;有2人认为通过临床路径进行“标准化”不能够达到地域间的协同医疗。(9)50人中有35人认为医院临床科室、其他医疗部门及相关行政部门关于临床路径的协作配合情况好;有9人认为医院临床科室、其他医疗部门及相关行政部门关于临床路径的协作配合情况一般;有6人认为医院临床科室、其他医疗部门及相关行政部门关于临床路径的协作配合情况差。14、(1)50人中有40人认为实施临床路径管理后达到了减少医生过度医疗和减少医疗费用的目的;有10人认为实施临床路径管理后没有达到减少医生过度医疗和减少医疗费用的目的。(2)50人中有45人认为实施临床路径管理后达到了减少患者住院天数的目的;有5人认为实施临床路径管理后未达到减少患者住院天数的目的。(3)50人中有35人认为实施临床路径管理后,达到了提高患者满意度和缓和医患关系的目的;有15人认为实施临床路径管理后,没有达到提高患者满意度和缓和医患关系的目的。(4)50人中有29人认为实施临床路径管理后达到了降低手术并发症、提高医疗质量的目的;有21人认为实施临床路径管理后没有达到降低手术并发症、提高医疗质量的目的。(5)50人中有42人认为实施临床路径管理后更加规范了抗菌药物的使用;有8人认为实施临床路径管理后没有规范了抗菌药物的使用。(6)50人中有37人认为实施临床路径管理后没有限制医疗技术的进一步提高;有13人认为实施临床路径管理后限制了医疗技术的进一步提高。结论:(1)实施临床路径管理后,患者的住院时间缩短,住院总费用及各项费用明显降低,患者的经济负担得以减轻。(2)实施临床路径管理后,患者的并发症发生率没有显著差异,可以保障医疗质量。(3)诊疗行为更加规范,护理行为也更加规范,患者也更加清晰了解自己的治疗过程。患者的医疗满意度明显提高。(4)医护人员对于临床路径的实施总体上表示肯定及支持,但各医护对于临床路径的相关认知仍存在差异,医护人员之间的临床路径实施、配合意识尚有待提高。医护及医院应该从自身角度减少变异的发生。更多还原

【Abstract】 Objective: In this study,we studied the cost of hospitalization,length of hospital stay,preoperative preparation time,treatment cost,drug cost and auxiliary examination cost in the study of benign prostatic hyperplasia patients in five urology hospitals in Qiqihar area.At the same time through the organization of the questionnaire on the implementation of the clinical path of the medical staff of the clinical path of the implementation of the evaluation results,the organization of patients through the questionnaire to conduct hospital patient satisfaction survey.So as to assess the quality of the clinical path in order to provide important scientific reference for the relevant departments,while exploring the clinical path for medical reform to provide rationalization recommendations.Metholds: Collected from January 2015 to December 2015 in Qiqihar City,five comprehensive top three hospital urology surgery and the implementation of clinical path management of benign prostatic hyperplasia in 100 patients,while the choice of five comprehensive top three hospital urology did not implement the period from January 2014 to December 2014,100 patients with benign prostatic hyperplasia were treated with clinical pathways as controls.All 200 patients underwent surgical treatment.The surgical procedure was transurethral resection of the prostate.Through the hospital medical records system were obtained in patients during the total cost of hospitalization,the average length of stay,preoperative preparation time,treatment costs,drug costs,auxiliary inspection costs.The questionnaire was used to investigate the satisfaction degree and the cognitive path of the clinical path.Analysis using SPSS19.0 statistical software,the comparison between the measurement data using t test,the difference between the count data using the chi-square test for comparison,p <0.05 that the difference was statistically significant.Results: 1、The age of the 100 patients in the experimental group was between 45 and 70 years,with an average age of(58.68 ± 8.25)years.The mean age of the 100 patients was between 48 and 67 years(59.22 ± 7.96)years.There was no significant difference between the experimental group and the control group in the mean age(t = 0.471,p =0.638).There was no significant difference between the two groups in the educational level(x~2 = 0.558,p =0.906).2、There were 5 patients with complications in the experimental group and 95 without complications.There were 4 patients with complications in the control group and 96 patients without complications.There was no significant difference in the incidence of postoperative complications between the experimental group and the control group(p =1.000).3、The total cost of hospitalization between(1.45 ± 0.18)million and total hospital costs(1.61 ± 0.22)patients in the control group during hospitalization million and total hospital costs total hospital costs of patients and the control group of patients in the experimental group during the hospital stay of patients in the experimental group The difference was significant,the experimental group was significantly lower than the control group(t = 5.629,p = 0.000).4、The average hospital stay was(9.38 ± 1.73)days in the experimental group and(10.56 ± 2.35)days in the control group.The average hospital stay was lower in the experimental group and the control group(t = 4.044,p =0.000).5、The average hospital stay was(1.27 ± 0.38)days in the experimental group and 1.73 ± 056 days in the control group.The difference between the experimental group and the control group was statistically significant.The preoperative preparation time of the experimental group was lower than that of the control group(t = 6.797,p =0.000).6、Drug costs patients in the experimental group(0.418 ± 0.109)million drug costs patients in the control group(0.497 ± 0.136)million,the difference between drug costs and drug costs patients in the control group of patients in the experimental group were statistically significant,the experimental group The cost of drug was lower than that of the control group(t = 4.533,p =0.000).7、experimental examinations cost patients(0.331 ± 0.085)million patients in the control group examinations costs(0.379 ± 0.112)million,the difference between the patient with the patient examination charges & auxiliary control inspection costs experimental groups was statistically(t = 3.414,p =0.001).8、Antibiotic drug cost was the experimental group(0.086 ± 0.015)million,an antibiotic drug costs for the patients in the control group(0.093 ± 0.027)million,the difference between the experimental group antibiotic patient drugs cost control group was statistically(t = 2.266,p =0.025).9、There were 98 patients in the experimental group who were satisfied with the medical process and two were dissatisfied with the medical process.In the control group,87 patients were satisfied with the medical process and 13 were not satisfied with the medical procedure.The difference between the patients in the experimental group and the control group was statistically significant for the medical satisfaction rate.The patients in the experimental group had higher satisfaction rate than the control group(x~2 = 8.721,p =0.003).10、Patients in the experimental group into the clinical pathway,a total of 26 cases of reasons mutation,including reasons of health care(4 cases),the reason patients(11 cases),because the hospital(3 cases)and causes of the disease(8 cases).11、There are 50 medical staff clinical pathway for understanding cognition policy of 41 people fully answer 4 questions,there are 5 people answer 3 questions,there are 4 people answer 2 questions.12、(1)50 people in 40 people believe that after the implementation of clinical pathway to reduce the excessive medical doctor and reduce medical cost;10 people think that after the implementation of clinical pathway fails to reduce excessive medical doctors and to reduce medical costs.(2)45 of the 50 patients agreed that the implementation of the clinical pathway management achieved the goal of reducing the number of hospital stay.5 people think that the implementation of the clinical pathway management did not achieve the goal of reducing the number of hospital stay.(3)50 people in 35 people believe that after the implementation of clinical pathway,to ease the doctor-patient relationship and improve the satisfaction of patients;15 of people believe that after the implementation of clinical pathway,not to improve the satisfaction and ease the doctor-patient relationship to patients.(4)29 people in 50 people believe that after the implementation of clinical pathway can reduce the complications,improve the quality of medical purpose;21 people believe that after the implementation of clinical pathway did not reach to improve medical quality and reduce surgical complications.(5)42 of the 50 patients considered that the use of clinical pathway management had more standardized the use of antimicrobials;8 believed that the use of antimicrobial agents did not regulate the use of clinical pathway management.(6)37 of 50 people believe that the implementation of clinical pathway management does not limit the further improvement of medical technology;13 believe that the implementation of clinical pathway management limits the further improvement of medical technology.13、(1)50 people have 35 people think that the most important clinical stage of implementation;11 people think that the most important evaluation and improvement stage;4 people think that the most important stage of development(2)35 of the 50 people think that the "clinical path management" and "single disease fees" are different concepts,combined with;11 people think different concepts,mutual restriction;4 people think that the same concept,the two statements.(3)43 of the 50 patients believed that the common diseases,frequent diseases,more costs,small differences in surgical or disposal methods,and the type of diagnosis needed for hospitalization were suitable for clinical pathway management.7 people believe that simple general type applies to clinical pathway management.(4)38 people in 50 people believe that the optimization process,to speed up the diagnosis efficiency is prompted into the factors of clinical pathway management;7 people think work to strengthen the ability of medical staff,improve the technology level of the led into the factors of clinical pathway management;5 people that accelerate the turnover of beds increase the economic benefit of hospitals is to promote the patient into the factors of clinical pathway management.(5)46 of 50 people considered it necessary to perform clinical pathways in hospitals and departments;4 considered it unnecessary to develop clinical pathways.(6)47 of 50 people considered the clinical pathway to be successful;3 believed that clinical pathways should be carried out in the future.(7)36 of 50 people think that the hospital management concept is the biggest challenge facing the development of clinical path;9 people think the concept of medical personnel is the biggest challenge facing the development of clinical path;5 people think the current hospital payment afterwards is the biggest challenge facing the development of clinical pathway.(8)48 of 50 people think of "standardization" to achieve coordination between regions through the medical clinical pathway;2 people think of "standardization" can not achieve synergy between regions through the medical clinical pathway.(9)36 of 50 people in that hospital clinical departments,medical departments and other relevant administrative departments of collaboration of clinical pathway with the situation;9 people think the hospital clinical departments,medical departments and other relevant administrative departments of collaboration of clinical pathway with the situation;6 people think the clinical departments,hospitals and other health departments and relevant administrative departments on the collaboration of clinical pathway with difference.14、(1)40 of 50 people believe that after the implementation of clinical pathway to reduce the excessive medical doctor and reduce medical cost;10 people think that after the implementation of clinical pathway fails to reduce excessive medical doctors and to reduce medical costs.(2)45 of the 50 patients agreed that the implementation of the clinical pathway management achieved the goal of reducing the number of hospital stay.5 people think that the implementation of the clinical pathway management did not achieve the goal of reducing the number of hospital stay.(3)35 of 50 people believe that after the implementation of clinical pathway,to ease the doctor-patient relationship and improve the satisfaction of patients;15 people believe that after the implementation of clinical pathway,not to improve the satisfaction and ease the doctor-patient relationship to patients.(4)29 of 50 people believe that after the implementation of clinical pathway can reduce the complications,improve the quality of medical purpose;21 people believe that after the implementation of clinical pathway did not reach to improve medical quality and reduce surgical complications,the purpose of.(5)42 of the 50 patients considered that the use of clinical pathway management had more standardized the use of antimicrobials;8 believed that the use of antimicrobial agents did not regulate the use of clinical pathway management.(6)37 of 50 people believe that the implementation of clinical pathway management does not limit the further improvement of medical technology;13 believe that the implementation of clinical pathway management limits the further improvement of medical technology.Conclusions: After the implementation of clinical path management,the patient’s hospital stay shortened,the total cost of hospitalization and the cost was significantly reduced,the patient’s economic burden can be reduced.The incidence of complications in patients is reduced.Treatment behavior is more standardized,care behavior is more standardized,patients also more clearly understand their own treatment process.Promote the communication between doctors and patients,the patient’s medical satisfaction improved significantly.Health care workers for the implementation of the clinical path of the overall affirmation and support,but the medical care for the clinical path of the relevant cognition is still different,the clinical path between health care workers,with the awareness has yet to be improved.Health care and hospitals should reduce the occurrence of variation from their own point of view.更多还原