基于评价指标的慢性心力衰竭治疗质量的趋势与变异

目的 分析2011-2017年慢性心力衰竭(HF)治疗质量评价指标使用率变化趋势,计算HF治疗质量综合得分,获得综合质量变化趋势及变异,为提高HF治疗质量提供依据。方法 选择HF治疗指南I类推荐的治疗质量评价指标12项,在单病种质量管理与控制平台中提取数据,计算HF评价指标使用率,基于分母权重法计算每年治疗质量综合得分及变异,并进行趋势性检验。结果 与2011年相比,12项治疗质量指标中,左心室功能评价使用率增幅最大,健康教育使用率下降最大,趋势性检验有统计学意义。2011年至2017年间,医院综合得分中位数随时间增大(0.77～0.81),四分位数间距随时间有增加趋势。结论 2011-2017年间,我国HF的多数治疗质量指标使用率有显著上升趋势,少数指标使用率下降,医院治疗质量综合得分升高,但医院间变异扩大,提示进一步提升HF治疗质量同时应关注医院间的质量差异。     

基于结直肠癌患者医生治疗质量指标评价

目的通过单指标使用率及多指标综合得分进行医生结直肠癌治疗质量评价,为结直肠癌治疗质量的改善及医生的绩效考核提供依据。方法收集哈尔滨市四家医院内出院时间为2011年6月-2013年6月的结直肠癌患者病历信息共1 559份;利用适合使用某评价指标的患者数为分母,适合该指标中实际使用的患者数为分子,计算某评价指标的使用率;利用潜变量模型及贝叶斯参数估计方法,整合多维评价指标,获得医生结直肠癌治疗质量的综合得分。结果不同医生对评价指标的使用率之间存在较大的差异,术前检查生化指标、肾功能、胸部X线使用率的变异范围为3.9%~97.8%,病理报告中记录检出淋巴结数和阳性淋巴结数使用率的变异范围为95.9%~100.0%;根据潜变量模型计算的综合质量得分,医生的综合质量得分最高为xita[12]=0.405 7,即该医生的治疗质量最好;其次为xita[1]=0.3875;最低为xita[3]=-0.596 7。结论整合多维评价指标获得综合质量得分,可以多角度全面地对医生治疗质量进行综合评价;计算单指标使用率,可以在综合评价的基础上得到医生对各评价指标的使用情况。     

基于分位数回归乳腺癌患者的治疗质量影响因素

目的利用分位数回归分析获得乳腺癌患者治疗质量的影响因素,为乳腺癌患者治疗质量的改善提供依据。方法收集符合条件的浸润性乳腺癌病例,利用治疗质量评价指标,计算乳腺癌患者治疗质量指标的使用率,计算综合得分并对综合得分按患者特征进行统计描述,利用分位数回归方法对综合得分进行影响因素分析。结果接受四周期以上辅助化疗的指标使用率最高,保乳手术的指标使用率最低。乳腺癌患者分位数回归影响因素分析结果显示:医院类型和患者收入在各分位点对治疗质量均有影响,专科医院的治疗质量优于综合性医院;患者收入越高接受的治疗质量越好;在不同分位点,患者保险类型、病理分期、患者年龄、合并症数量的回归系数统计学意义会发生改变。结论分位数回归可提供更多的数据信息,获得各分位点患者治疗质量的影响因素,为改善低治疗质量的乳腺癌患者提供理论依据。     

全国急性ST段抬高型心肌梗死（STEMI）医疗服务与质量安全报告分析

目的 了解我国急性ST段抬高型心肌梗死(STEMI)医疗服务与质量安全工作现状，为急性STEMI医疗质量持续改进提供参考。方法 基于国家单病种质量管理与控制平台，收集并分析2019年-2020年二、三级医院急性STEMI相关数据，利用SAS 9.4软件对数据进行分析。结果 2020年急性STEMI患者平均住院日二、三级医院间与地区间均有所差异；各地区住院费用相比2019年呈减少趋势(P<0.05)。过程指标中，检查及循证药物使用情况2020年较2019年有所改善，发病12 h内到院患者再灌注治疗率总体为72.1%,其中到院90 min内进行直接PCI的比例为43.4%,在三级医院较高，溶栓患者到院30 min内溶栓治疗的比例为35.3%,二级医院高于三级医院。结局指标中，2020年住院死亡率总体为1.8%,三级医院2020年住院死亡率较2019年增加明显(P<0.05),各地区住院死亡率存在差异。结论 我国急性STEMI医疗服务质量地区间和医疗机构级别间存在差异。医疗机构应持续关注急性STEMI过程指标及结局指标，国家心血管病医疗质量控制中心应继续开展医疗质量改进行动，推动...     

基于综合指数法的某三级医院医疗质量综合评价研究

[目的]分析某三级医院2011-2015年医疗质量,为医院管理者制定决策提供科学的依据。[方法]使用该院2010-2015年信息统计中心的统计年报表数据,按照工作强度、工作效率、医疗技术质量和医疗费用四大类共12项指标,采用综合指数法进行医疗质量的综合评价。[结果]近5年该院医疗质量指数逐年增长,医疗质量最好的是2015年,综合指数为5.19;最差的是2011年,综合指数为3.17,2015年的综合指数是2011年的2.48倍。[结论]该院2010-2015年工作强度指标呈增长趋势,工作效率指标出现波动性调整,医疗技术质量指标趋于平稳状态,医疗费用指标逐年上升,综合指数逐年上升,医疗质量不断提高。     

美国医院比较数据库中农村医院质量分析

背景:美国国家公共报告中指出,农村医院对循证指南的依从性低于城市医院。该研究利用一项新的包含过程指标的国家数据库——医院比较系统,对农村医院和城市医院的质量进行了比较分析。方法:对2005年医院比较系统报告中参与调查的医院进行横断面分析,利用多变量线性回归评估急性心肌梗死(AMI),心脏衰竭(HF),社区获得性肺炎(CAP)等10个卫生保健过程指标的依从性比例。结果:参与调查的农村医院在急性心肌梗死和心衰等服务质量指标方面的循证指南依从性较低(P0.05),在社区获得性肺炎患者给予及时抗生素治疗方面的依从性较高(P0.05)。农村与城市医院的这种差异随着床位数的增加而增大(线性趋势的F检验,P0.05)。在校正了由于部分低绩效农村医院退出的因素之后,这种趋势在6项AMI和HF指标(低依从性)和1项CAP指标(高依从性)中依然存在。结论:参与调查的农村医院比城市医院的绩效低。由于农村/城市医院质量随疾病体种类、床位数、参与情况而变化,建议为使质量改进具有针对性,需分别比较多种疾病的情况。     

医院院长应重视的四项效益指标

浙江省医院综合效益评价指标共有19项，包括医疗质量指标5项、医疗效益指标3项、医院效益指标11项。开展综合评价对于提高医疗质量和医院效益有很好的促进作用。作为医院院长必须及时分析医院效益指标和质量指标的动态变化，针对薄弱环节，及时采取必要措施。     

应用综合指数法评价医院住院医疗质量

目的：通过对某三级医院近10年住院医疗质量指标进行评价分析,了解该院医疗质量现状和变动趋势,为医院管理层研究对策、完善措施、提升医疗水平提供有价值的信息资料。方法采用综合指数法对该院2004年至2013年住院医疗质量12项指标进行评价分析。结果该院2004年至2013年住院医疗指标综合指数逐年递增。其中工作强度增幅最大,治疗质量稳步上升,工作效率有所提高,但诊断质量有所下滑。结论该院2004年至2013年间住院医疗质量不断提升。平均住院日逐年缩短,病床周转次数逐年提高。医院在继续狠抓医疗质量的同时,应适当引进人才并加大人才培养力度,减轻医务人员超负荷工作量,才能降低技术难度,真正以精湛技术为桥梁,充分发挥医院的综合实力。     

产科服务效率对产科质量重点指标的影响

目的:探索产科服务效率对产科质量重点指标的影响。方法:选取广州市Ⅳ类助产机构作为评价对象,用趋势卡方检验方法分析产科质量指标随服务效率的变化趋势。结果:新生儿窒息发生率和产后出血发生率随服务效率的增加呈上升趋势,未发现围产儿死亡率随服务效率的升高而发生变化。结论:产科医生与助产士服务效率影响产科质量的重点指标。     

质量指标评价体系在手术室医院感染预防中的应用研究

目的 分析质量指标评价体系在手术室医院感染预防中的应用效果,为手术室医院感染防控提供借鉴。方法采用回顾性分析方法调查实施质量评价前后的手术室医院感染预防效果。选取2019年1月—2021年10月承德市中心医院手术科收治的1 025例患者及医护人员40例为研究对象,其中质量指标评价体系实施前为2019年1月—2020年6月,实施前患者共515例;质量指标评价体系实施后为2020年7月—2021年10月,实施后患者共510例,医护人员无变化。对比质量指标评价体系实施前后质量评价指标及医护人员预防感染相关知识、态度、行为评分和患者满意度。结果 与质量指标评价体系实施前相比,实施后Ⅰ类切口手术部位感染发病率、医院感染发病率、导尿管相关泌尿道感染发病率、多重耐药菌医院感染发病率、呼吸机相关性肺炎发病率、中央血管导管相关血流感染发病率、Ⅰ类切口手术抗菌药物预防使用率、多重耐药菌检出率、医院感染病例漏报率、住院患者抗菌药物预防使用率均下降(P<0.05)。实施后多重耐药菌感染防控措施执行率、中心静脉导管使用率、呼吸机使用率、导尿管使用率、治疗性抗菌药物使用前病原学送检率均高于实施质量指标评价体...     

Comparing a multivariate response Bayesian random effects logistic regression model with a latent variable item response theory model for provider profiling on multiple binary indicators simultaneously

Provider profiling entails comparing the performance of hospitals on indicators of quality of care. Many common indicators of healthcare quality are binary (eg, short-term mortality, use of appropriate medications). Typically, provider profiling examines the variation in each indicator in isolation across hospitals. We developed Bayesian multivariate response random effects logistic regression models that allow one to simultaneously examine variation and covariation in multiple binary indicators across hospitals. Use of this model allows for (i) determining the probability that a hospital has poor performance on a single indicator; (ii) determining the probability that a hospital has poor performance on multiple indicators simultaneously; (iii) determining, by using the Mahalanobis distance, how far the performance of a given hospital is from that of an average hospital. We illustrate the utility of the method by applying it to 10 881 patients hospitalized with acute myocardial infarction at 102 hospitals. We considered six binary patient-level indicators of quality of care: use of reperfusion, assessment of left ventricular ejection fraction, measurement of cardiac troponins, use of acetylsalicylic acid within 6 hours of hospital arrival, use of beta-blockers within 12 hours of hospital arrival, and survival to 30 days after hospital admission. When considering the five measures evaluating processes of care, we found that there was a strong correlation between a hospital's performance on one indicator and its performance on a second indicator for five of the 10 possible comparisons. We compared inferences made using this approach with those obtained using a latent variable item response theory model.     

我国中部某地区急性ST段心肌梗死医疗质量研究

目的研究我国中部某地区急性ST段心肌梗死住院病例医疗质量,寻找原因,并针对性改进。方法从中国胸痛中心总部数据库获取2018年1月-6月我国中部某地区5家医院1 172例STEMI住院患者数据,以是否入院90 min内实施PCI、是否绕行CCU、是否进行双联抗血小板治疗、首次医疗接触时间至双联抗血小板治疗时间是否小于等于10min、是否入院24h内强化他汀治疗、是否出院后继续使用β阻滞剂、是否出院后继续使用他汀类药物、是否院内死亡8个变量为评价指标,建立线性概率模型控制年龄和性别后,分析不同医院间的医疗质量     

Organizational resiliency: how top-performing hospitals respond to setbacks in improving quality of cardiac care

Despite substantial improvement in recent years in hospital performance in many quality measures for acute myocardial infarction (AMI), national performance lags in a key publicly reported quality indicator for AMI--door-to-balloon time, the period from patient (with ST-segment elevation myocardial infarction or STEMI) arrival to provision of percutaneous coronary intervention or balloon angioplasty. Previous research has elucidated distinguishing features of hospitals that routinely achieved recommended door-to-balloon times for patients with STEMI. However, what has not been fully explored is how top-performing hospitals handle setbacks during the improvement process. In this study, we used qualitative methods to characterize the range of setbacks in door-to-balloon improvement efforts and the strategies used to address these barriers among hospitals that were ultimately successful in reducing door-to-balloon time to meet clinical guidelines. Setbacks included (1) failure to anticipate and address implications of initial changes in door-to-balloon processes for the system as a whole; (2) tension between and within departments and disciplines, which needed to gain consensus about how to reduce door-to-balloon time; and (3) waning attention to door-to-balloon performance as a top priority after the perceived goal of reducing treatment times had been reached. Our findings demonstrate key aspects of technical capacity, organizational culture, and environmental conditions that were factors in maintaining improvement efforts despite setbacks and hence may be critical to sustaining top performance. Understanding how top-performing hospitals recognize and respond to setbacks can help senior management promote organizational resiliency, leading to an environment in which learning, growth, and quality improvement can be sustained.     

基于变异系数赋权与功效系数的医院综合评价

目的 为了解湛江市二级综合医院的医疗质量状况,对9家医院综合水平进行排序,找出某院与同行的差距,以及需要改进之处,为该院的发展提供决策依据.方法 从国家卫生统计信息网络直报系统提取2009年湛江市九家二级医院的直报数据,根据广东省卫生厅采用的指标公式整理并提取病床使用率、病床周转次数、平均住院日、病床工作日、有效率、病死率、住院危重病人抢救成功率、急诊抢救成功率、三日确诊率、入出诊断符合率、药品比例、平均每医生收治住院病人数、平均每医生负担诊疗人次、平均每诊疗人次医疗费、出院者平均每天住院医疗费等15个有代表性的医疗质量、效率指标.使用变异系数赋权与功效系数法,对这九家医院的上述指标进行综合评价.首先运用Excel求出标准差及变异系数,根据指标包含的信息确定权重,再计算功效系数,然后采用加权几何平均法计算出总功效系数,对结果进行排序.结果 A～I代表的九家医院医疗质量总功效系数分别为68.7、79.1、71.9、86.5、86.0、79.5、87.6、83.3、90.3.I单位平均住院日等4个指标排名第1,2个指标排第2,综合水平名列前茅;G单位病死率等3个指标排第1,平均住院日排第2,3个指标排第3,综合水平第2;A单位虽然出院者平均每天住院医疗费排第1,有效率排第2,但是病床使用率等权重较大的8个指标排在第8或9,综合水平排名最后.结论 A单位在医疗技术培训、抢救水平、外科及儿科建设、宣传等方面要加大力度,提升医疗质量.     

Myocardial Infarction Registry--2010. Experience and first results in Hungary

Authors present the methodology and first data of Hungarian Myocardial Infarction Register Pilot Study started 1st of January, 2010. The aim of the study is to collect epidemiological data on myocardial infarction, to examine the natural history of the disease and to investigate the main characteristics on patient care in the pilot area. The program is using standardized diagnostic criteria and predefined electronic data record forms (eCRF). The pilot area consists of 5 districts in the capital, and Szabolcs-Szatmár-Bereg county. The area has 997 324 inhabitants. Eight cardiology departments, 5 with heart catheterization facility (C) in Budapest, four hospitals with one C in Szabolcs-Szatmar-Bereg county have been responsible of the patients' care. After starting the program 16 other hospitals joined the program from different parts of Hungary. Between 1st of January 2010 and 1st of May 2011 4293 patients were registered, among them 52.1% with ST segment elevation myocardial infarction (STEMI), 42.1% with non-ST segment elevation myocardial infarction (NSTEMI), while 3% of the patients had unstable angina, and 2.8% of the cases had other diagnosis or the hospital diagnosis was missing in the eCRF. Authors compare the patients care with STEMI in five districts of Budapest and Szabolcs-Szatmár-Bereg county. In Budapest 79.7% of the 301 STEMI patients were treated in C and 84.6% of them were treated with primary percutaneous intervention (pPCI). In Szabolcs-Szatmár-Bereg county 402 patients were registered with STEMI, 62.9% of them were treated in C, where 77% of them were treated with pPCI. The drugs (beta blockers, ACE inhibitors, statins) important for secondary prevention were given more often to patients treated in the capital, however no difference was found in the platelet aggregation inhibitors therapy. Hospital mortality of STEMI patients was 8% in the capital, and 10% in Szabolcs- Szatmár-Bereg county. Authors conclude that the web based myocardial infarction register is feasible and important to have reliable data on patient care and a necessary quality control tool. Authors propose to broaden this pilot program and to start a nationwide myocardial infarction register.     

基于胸痛中心的区域协同救治体系建设实践*

为改变我国急性ST段抬高心肌梗死(STEMI)患者的救治现状,国内以广州军区总医院及上海胸科医院为首,相继成立了基于胸痛中心的STEMI区域协同救治体系。嘉定区中心医院自2016年5月12日成立嘉定区胸痛中心,截止2018年4月30日共收治了9 002例胸痛患者,其中STEMI患者363例,急性非ST段抬高心肌梗死(NSTEMI)患者203例。通过医疗资源整合、建立区域协同快速救治体系及优化院内胸痛救治流程,有效缩短了患者门-球(Door to Balloon,D2B)时间,提高了急性心肌梗死救治成功率。     

From Multiple Quality Indicators of Breast Cancer Care Toward Hospital Variation of a Summary Measure

ObjectivesTo improve quality in breast cancer care, large numbers of quality indicators are collected per hospital, but benchmarking remains complex. We aimed to assess the validity of indicators, develop a textbook outcome summary measure, and compare case-mix adjusted hospital performance.MethodsFrom a nationwide population-based registry, all 79 690 nonmetastatic breast cancer patients surgically treated between 2011 and 2016 in 91 hospitals in The Netherlands were included. Twenty-one indicators were calculated and their construct validity tested by Spearman’s rho. Between-hospital variation was expressed by interquartile range (IQR), and all valid indicators were included in the summary measure. Standardized scores (observed/expected based on case mix) were calculated as above (>100) or below (<100) expected. The textbook outcome was presented as a continuous and all-or-none score.ResultsThe size of between-hospital variation varied between indicators. Sixteen (76%) of 21 quality indicators showed construct validity, and 13 were included in the summary measure after excluding redundant indicators that showed collinearity with others owing to strong construct validity. The median all-or-none textbook outcome score was 49% (IQR 42%-54%) before and 49% (IQR 48%-51%) after case-mix adjustment. From the total of 91 hospitals, 3 hospitals were positive (3%) and 9 (10%) were negative outliers.ConclusionsThe textbook outcome summary measure showed discriminative ability when hospital performance was presented as an all-or-none score. Although indicator scores and outlier hospitals should always be interpreted cautiously, the summary measure presented here has the potential to improve Dutch breast cancer quality indicator efforts and could be implemented to further test its validity, feasibility, and usefulness.     

基于收支结构变动度模型的专科医院发展特点与挑战分析

目的：分析样本专科医院2017—2021年收支结构变化的特征及趋势,论证公立医院综合改革实践及其相关政策对专科医院可持续发展的积极作用。方法：借助2017—2021年样本专科医院财务收入和支出相关指标与数据,利用结构变动度模型进行系统分析。结果：医疗服务收入占比持续提升,药品、卫生材料、检查和化验收入占比持续下降,且政府财政补助占比也呈下降趋势。结论：公立医院综合改革实践成效明显,促进了专科医院的转型发展,但需进一步完善医院综合改革措施,有效地保障公立医院的可持续发展。     

2015年-2017年全国三级医院护理质量分析

目的分析2015年-2017年我国三级医院护理质量现状,为质量持续改进提供依据。方法从国家护理质量数据平台提取2015年-2017年护理质量相关数据,分析各指标数据的变化情况。结果（1）截止2017年,所有指标的完整性均超过98%。（2）床护比、护患比与24小时平均护理时数3项指标3年均保持相对稳定。（3）2015年-2017年三级医院本科及以上护士占比增长明显,3年增加8.12%;5年及以上年资护士占比稳步提升,3年增加5.36%;2015年-2017年三级医院护士离职率稳步下降,3年下降0.24%。（4）2015年-2017年三级医院住院患者身体约束率中位数分别为1.38%、1.36%、1.60%,呈现波动变化,2017年增长较为明显。（5）护士执业环境中的“医院管理参与度”“薪酬待遇”与“社会地位”等维度得分较低。结论（1）经过两年护理敏感质量指标理念与数据收集的培训,三级医院护理质量指标数据变异度逐渐减小,数据完整性与可靠性得到提升;（2）护理人员绝对数量的增加并未改善护理人员相对不足的现状;（3）护理人力结构得到优化,队伍稳定性增强;（4）约束、跌倒等指标逐年升高,侧面印证了数据上报文化逐步形成和数据逐渐趋于真实与可靠;（5）护士执业环境测评结果表明,薪酬待遇及社会地位是制约护理行业的关键因素。     

Discriminating quality of hospital care in the United States.

BACKGROUND AND OBJECTIVE: The Centers for Medicare and Medicaid Services (CMS) report quality of care for patients hospitalized with acute myocardial infarction (AMI), congestive heart failure (CHF), and community-acquired pneumonia (CAP) with the intention of rewarding superior performing hospitals. The aim of the study was to compare identification of superior hospitals for providing financial rewards using 2 different scoring systems: a latent score that weights individual clinical performance measures according to how well each discriminated hospital quality and a raw sum score (the system adopted by CMS). METHODS: This observational cohort study used 2761 acute care hospitals in the United States reporting AMI clinical performance measures, 3271 reporting CHF measures, and 3714 hospitals reporting CAP measures. For each clinical condition, the main outcome measures included the average raw sum score, the latent score estimated from an item response theory (IRT) model, and the percentage of false negative superior designations made on the basis of raw sum scores relative to latent scores. RESULTS: The average raw sum score was highest for AMI (88.8%) and lower for CHF (73.1%) and CAP (76.3%). AMI measures were equally nondiscriminating of hospital quality; hospital discharge instruction was most discriminating of CHF quality; pneumococcal vaccination was most discriminating of CAP quality. False negative rates varied 2-fold: AMI (10%), CHF (16%), and CAP (24%). CONCLUSIONS: Neither the AMI raw sum score nor latent score discriminates hospital quality due to ceiling effects. Current methods for aggregating measures result in different hospital superior designations than those based on the latent score. Organizations that financially reward hospitals on the basis of such scores need to assess predictive validity of scores and determine a minimum level of classification accuracy.