【作者】 向华；

【导师】 邱景富；

【作者基本信息】 重庆医科大学 ， 公共管理（MPA）（专业学位）， 2019， 硕士

【摘要】 随着医学技术进步医用耗材在临床中发挥着越来越重要的作用,但随之而来的是医疗成本的快速增长。新医改的重要目标是控制患者医疗费用的快速上涨,降低医疗成本,同时给出“三医”联动改革的思路与目标,实行单病种收费及单病种的临床路径管理模式等指导意见。本课题主要从手术患者的医用耗材费用整体变化着手,通过几种常见的疾病患者手术方式与诊断的不同来研究单病种手术患者医用耗材费用的特点及其规律性,并结合医疗服务价格的收费标准与医保的单病种限价,研究不同病种手术患者医用耗材费用现状及存在问题,为医院下一步单病种的临床路径实施、医用耗材的使用规范与标准的制定提供依据。目的:研究手术患者医用耗材费用的年度整体变化情况,确定医院手术患者的次均费用、医用耗材费用的年度变化现状;研究单病种、单手术方式手术患者的医用耗材费用年度的变化情况及不同诊断不同术式对同类疾病患者医用耗材费用的影响,进一步为临床医用耗材的合理使用提供依据。方法:通过A医院HIS系统调取2016年-2018年手术患者的收费数据信息,包含病人ID、年龄、住院日、诊断与主要手术等信息,及各项患者的费用项目明细,按照年度分别计算患者的医用耗材次均费用、患者总入院费用等值;从2016年-2018年数据中选取常见几类疾病的诊断与手术方式进行分类研究,采取SPSS22.0软件进行数据分析不同诊断/手术方式患者医用耗材费用的差异性,包括年度差异性及同类别不同诊断之间的差异性。对于例数n<1000的组的正态性检验采用Shapiro-Wilk方法,例数n>1000的组的正态性检验采用Kolmogorov-Smirnova方法检验。在进行多组间医用耗材费用比较时,满足样本正态性和方差齐性,采用方差分析;不满足样本正态性分布或方差齐性的,采用Kruskal-Wallis H检验。进行两组间医用耗材费用比较时,满足样本正态性分布的,采用两独立样本T检验;不满足样本正态性分布的,采用两独立样本的Wilxocon秩和检验。P<0.05为差异具有统计学意义。结果:2016-2018年整体手术患者的次均费用先升后降,患者医用耗材次均费用逐年上涨。单种疾病中剖宫产、双侧扁桃体切除、开腹阑尾切除、开腹胆囊切除、微创胆囊切除、白内障超声乳化手术(左眼与右眼)等手术方式患者的医用耗材费用在2016-2018年之间的两两比较结果存在统计学差异有:剖宫产P<0.0001;双侧扁桃体切除(扁桃体肥大与慢性扁桃体炎)均为P<0.0001;阑尾切除手术,开腹P<0.0001,微创P=0.0428;阑尾切除手术(开腹)(急性化脓性阑尾炎与急性阑尾炎)均为P<0.0001;胆囊切除手术(不同术式),开腹P<0.0001,微创P<0.0001;胆囊切除手术(不同诊断),胆囊结石伴慢性胆囊炎P<0.0001,胆囊结石伴急性胆囊炎P=0.0011,胆囊息肉P<0.0001;白内障诊断的手术(左眼白内障超声乳化术与右眼白内障超声乳化术)均为P<0.0001);而医用耗材费用不存在统计学差异的有:胆囊切除手术开腹转微创P=0.2124;胆囊结石P=0.2145。2018年,扁桃体肥大与慢性扁桃体炎两组诊断的双侧扁桃体切除手术患者之间医用耗材费用不存在统计学差异(P=0.1164);急性化脓性阑尾炎与急性阑尾炎诊断的阑尾切除术(开腹)手术患者医用耗材费用之间不存在统计学差异(P=0.0949),腹腔镜胆囊切除手术中不同诊断组之间手术患者医用耗材费用不存在统计学差异(P>0.05),不同手术部位(左眼与右眼)之间白内障超声乳化术手术患者的医用耗材费用不存在统计学差异(P=0.7244)。结论:手术患者的医用耗材费用在患者的总入院费用中占有重要比例;与重庆市的医保单病种限价标准相比本研究中单病种手术患者的医用耗材费用较高,医用耗材成本较高;不同诊断相同手术方式之间手术患者医用耗材费用的差异性结果有助于我们进行单病种医用耗材临床使用的规范管理,为单病种临床路径在医院中的实施、医用耗材的合理使用管理提供重要参考,为进一步医改控费与医院耗材成本的降低提供管理依据。更多还原

【Abstract】 With the development of medical technology,medical consumables are playing an increasingly important role in clinical practice.However,it also causes the rapid increase of medical costs.One of the important objectives of the new healthcare reform is to control the rapid rise of patients’ medical expenses and reduce medical costs.Meanwhile,the new reform brought some new thoughts and objectives on the linkage reform of health care,medical insurance and medicine,and the guidance to use the payment system of single disease and single disease clinic pathways,etc.This study focus on the general changes of the surgical patients’ medical consumables expenses,to explore the regularity of medical consumables costs of the surgical patients with single disease by investigating several common single diseases and surgeries,to conclude the current situation and characteristics of consumables costs of surgical patients with different diagnostic diseases based on the standard of the medical service charges and the limitation of price charge for single disease,which lay the basis to set norms and standards for medical consumables use in single disease clinical pathways.Objectives: To reveal the annual changes of patients’ mean costs of per surgery and their mean costs of medical consumables by studying the annual overall changes in medical consumables costs of surgical patients.To figure out the annual changes in costs of medical consumables for single disease and single surgery;and the effect of different diagnosis and surgical procedures on the consumables costs for similar diseases.Methods: Surgical patients’ information during 2016 to 2018 was collected from hospital information system(HIS),including each patient’s ID,age,length of hospital stay,diagnosis,major surgery and details of charges.Annualize the mean costs of consumables and the total hospitalization fee of each patient.Several common single diseases and surgeries are selected and classified for study,mainly analyzed the differences of consumables costs of the patients with different diagnosis/surgeries,including the annual differences and the differences among different diagnosis in the same category.The Shapiro-Wilk method was used to test the normality of the group n<1000,and kolmogorov-smirnova method was used to test the normality of the group n>1000.When comparing the cost of medical consumables among multiple groups,anova is used when the sample normality and homogeneity of variance are satisfied.Kruskal-wallis H test is adopted for those samples that do not meet the normal distribution or homogeneity of variance.When comparing the cost of medical consumables between two groups,T test of two independent samples is adopted to meet the sample normality.Wilxocon rank sum test of two independent samples was adopted for those samples that did not meet the normal distribution of samples.P < 0.05 for the difference is statistically significant.Results: From 2016 to 2018,the total mean costs of per surgery increased first and then decreased.The mean costs of medical consumables increased year by year.There exists a statistical difference in pair comparison between 2016 and 2018 for patients’ costs of medical consumables in surgeries of such a single disease as cesarean section,bilateral tonsillectomy,open appendectomy,open cholecystectomy,minimally invasive cholecystectomy,cataract phacoemulsification(left eye and right eye)and other surgical methods.The P values as follows: cesarean section(P<0.0001);bilateral tonsil excision(tonsil hypertrophy and chronic tonsillitis)(P<0.0001);open appendectomy(P<0.0001),minimal invasive appendectomy(P=0.0428);open appendectomy for acute purulent appendicitis(P<0.0001),open appendectomy for acute appendicitis(P<0.0001);open cholecystectomy(P<0.0001),minimal invasive cholecystectomy(P<0.0001),open turn minimal invasive cholecystectomy(P=0.2124);cholecystectomy for gallstone with chronic cholecystitis(P<0.0001),cholecystectomy for gallstone with actual cholecystitis(P=0.0011),cholecystectomy for gallbladder polypi(P<0.0001),cholecystectomy for gallstone(P=0.2145);phacoemulsification in left and right eye(P<0.0001).In 2018,tonsil hypertrophy and diagnosis of chronic tonsillitis two groups of patients with bilateral tonsillectomy between medical consumables costs there is no statistical difference(P = 0.1164);Acute suppurative appendicitis and acute appendicitis diagnosis of appendectomy(open)surgery in patients with medical consumables cost does not exist between the statistical difference(P = 0.0949),laparoscopic gallbladder surgery surgery patients between different diagnosis group in medical consumables costs there is no statistical difference(P > 0.05),different surgical site(right and left eye)between the cost of medical consumables in patients with cataract phaco surgery there is no statistical difference(P = 0.7244).Conclusion: The costs of medical consumables accounts for a major proportion in the surgical patients’ hospitalization fee.Compared with the price limit standards of medical insurance for single disease in Chongqing,the patients with single disease expend more money on medical consumables in surgery,hospitals bear a high cost of medical consumables.Knowing the differences in the costs of medical consumables between patients with different diagnosis but same surgical procedures will help us to carry out standardized management for clinical use of medical consumables in single disease,single disease clinical pathways in hospitals and appropriate use and management of medical consumables.It also offers a basis for further healthcare reform to control the patients’ healthcare expenses and to reduce the medical consumables costs of hospital.更多还原