临床路径命名规范研究

梳理国家发布的临床路径命名现状,结合医疗机构实践中遇到的问题,提出规范的临床路径编码和命名规则设想。在目前临床路径分支路径制定与命名规则不统一的情况下,规范命名将有利于医疗机构内部精细化管理,有利于医疗机构间有效交流,有利于与DRG-PPS机制联动。     

DRG与DIP的改革实践及发展内涵

疾病诊断相关组(DRG)与基于大数据的病种分值付费(DIP),其设计思维和方案框架都来源于国际社会的疾病诊断相关组(DRG),区别在于DRG采取的是收敛的、取不同病种共性的最大公约数的分组原则,而DIP则采取更加具体细化的分组思路,其结果是国家医保局颁布的DRG有618个病组、DIP则有14052个病组。广州的DIP试点中,存在相当部分的人为、管理因素,导致支付不稳定和预测困难;沈阳的DRG试点方案相对稳定、客观、操作方便,对医疗机构行为和医疗资源配置产生了较好的效果。DIP只是完成全面DRG付费的一个过渡手段,随着地方实践的成熟,必将会形成更具科学性、系统性和长期性的医保支付体系。     

Teaching nursing in a situation of conflict: encounters between Palestinian‐Israeli and Jewish‐Israeli nursing students

ARIELI D. & HIRSCHFELD M.J. (2010) Teaching nursing in a situation of conflict: encounters between Palestinian‐Israeli and Jewish‐Israeli nursing students. International Nursing Review 57 , 312–320 Purpose: This research examines the ways Palestinian‐Israeli and Jewish‐Israeli nursing students, who study together in one group in an academic school of nursing situated in northern Israel, perceive each other and the relationships among them. Design: The study is based on semi‐structured interviews with undergraduate students. The cohort consists of 46 students, 20 of whom participated in the study. Findings: The students perceive themselves as divided into two separate groups according to nationality. Cooperation between the groups related to their study duties is described as generally satisfying, but little expressive communication and scarce social relations occur across these two groups. Students provided their perceptions of ‘the others’ to explain this social distance. Implications: We discuss the challenges of the situation for nursing educators and some strategies for coping with these challenges.     

Sports nutrition in a regulatory limbo

The regulatory framework governing sports nutrition products in Europe is changing, with new Regulation 609/2013 on Food for Specific Groups coming into force in July 2016. Currently, sports nutrition products are regulated under the general provisions of Directive 2009/39/EC on Foodstuffs Intended for Particular Nutritional Uses (PARNUTS), the so‐called ‘dietetic foods’. An attempt to set out separate provisions for sports nutrition products, such as food composition and labelling criteria, was made by the European Commission in 2004, but at that time a consensus was not agreed and no official activity was developed in this area. In 2011, in light of conflicting rules with more recent legislation, the European Commission agreed to repeal the ‘dietetic foods’ framework, removing the food categories for which no specific provisions exist, such as sports nutrition products. Today, the prospect of regulators bringing in specific legislation for the sports nutrition sector has receded, with Europe's policy makers recognising that sports people are not a vulnerable subgroup of the general population to require additional controls, as reflected in superseding Regulation 609/2013 on Food for Specific Groups. However, as some Member States remain concerned over consumer safety coming from the use of sports nutrition products, the European Commission has been asked to prepare a report addressing the need, if any, for additional specific rules to govern these food products. As we approach what may be a conclusion on a decade‐long debate about how to regulate sports nutrition products in Europe, thanks to these regulatory changes, the sector may now face a very different challenge. Initially, the industry was in danger of a legislation that was so restrictive that it could have prevented growth and innovation in the sector. Today, as sports nutrition products have evolved to attend to the needs of the wider active population, the industry is now in danger of a regulatory framework that is so broad that it does not recognise the specific needs of sports people. The Commission Report, due in July 2015, is crucial for settling the legislative framework governing sports nutrition products once and for all, so that concerns from National Authorities and the issues currently experienced by the industry are addressed, and the sector can eventually achieve legal clarity and ensure consumer protection. This article discusses the changing regulatory environment for sports nutrition products in Europe, according to the particular views of the European Specialist Sports Nutrition Alliance (ESSNA), the trade association representing the interests of the sports nutrition industry in Europe.     

Treatment Staff Referrals,Participation Expectations,and Perceived Benefits and Barriers to Adolescent Involvement in Twelve-Step Groups

Adolescents treated for substance use disorders (SUDs) appear to benefit from participation in Alcoholics Anonymous/Narcotics Anonymous (AA/NA). However, as compared with adults, fewer adolescents attend, and those who do attend do so less intensively and discontinue sooner. It is unknown whether this disparity is due to a lowered expectation for youth participation by the clinicians treating them, as they may adapt the adult-based model to fit a less-dependent cohort, or whether recommendations are similar to those of clinicians who work with adults and other factors are responsible. All clinical staff (N = 114) at 5 adolescent programs (3 residential, 2 outpatient) were surveyed anonymously about referral practices and other beliefs about 12-step groups. Staff rated AA/NA participation as very important and helpful to adolescent recovery and referral rates were uniformly high (M = 86%, SD = 28%). Desired participation frequency was over 3 times per week. The theoretical orientation and level of care of the programs influenced some results. Findings suggest lower adolescent participation in 12-step groups is not due to a lack of clinician enthusiasm or referrals, but appears to be due to other factors.     

Impact of obesity on adverse in-hospital outcomes in patients undergoing percutaneous mitral valve edge-to-edge repair using MitraClip® procedure - Results from the German nationwide inpatient sample

Background and aimThe number of percutaneous edge-to-edge mitral regurgitation (MR) valve repairs with MitraClip® implantations increased exponentially in recent years. Studies have suggested an obesity survival paradox in patients with cardiovascular diseases. We investigated the influence of obesity on adverse in-hospital outcomes in patients with MitraClip® implantation.Methods and resultsWe analyzed data on characteristics of patients and in-hospital outcomes for all percutaneous mitral valve repairs using the edge-to-edge MitraClip®-technique in Germany 2011–2015 stratified for obesity vs. normal-weight/over-weight.The nationwide inpatient sample comprised 13,563 inpatients undergoing MitraClip® implantations. Among them, 1017 (7.5%) patients were coded with obesity. Obese patients were younger (75 vs.77 years,P < 0.001), more often female (45.4% vs.39.5%,P < 0.001), had more often heart failure (87.1% vs.79.2%,P < 0.001) and renal insufficiency (67.0% vs.56.4%,P < 0.001). Obese and non-obese patients were comparable regarding major adverse cardiac and cerebrovascular events (MACCE) and in-hospital death. The combined endpoint of cardio-pulmonary resuscitation (CPR), mechanical ventilation and death was more often reached in non-obese than in obese patients with a trend towards significance (20.6%vs.18.2%,P = 0.066). Obesity was an independent predictor of reduced events regarding the combined endpoint of CPR, mechanical ventilation and death (OR 0.75, 95%CI 0.64–0.89,P < 0.001), but not for reduced in-hospital mortality (P = 0.355) or reduced MACCE rate (P = 0.108). Obesity class III was associated with an elevated risk for pulmonary embolism (OR 5.66, 95%CI 1.35–23.77,P = 0.018).ConclusionsWe observed an obesity paradox regarding the combined endpoint of CPR, mechanical ventilation and in-hospital death in patients undergoing MitraClip® implantation, but our results failed to confirm an impact of obesity on in-hospital survival or MACCE.     

疾病诊断相关分组应用中歧义病案的危险因素分析

目的探索疾病诊断相关分组(DRGs)应用中歧义病案产生的危险因素。方法以郑州人民医院2016年1月—2017年12月病案管理中根据主要诊断、主要手术选择筛选出100例歧义病案(实验组)和100份非歧义病案(对照组)为研究对象,对比两组的年龄、住院时间和并发症发生率等。结果实验组患者的年龄高于对照组,住院时间长于对照组(P0.05),且实验组患者的男性比例、转科比例、出院科别为内科比例、患肿瘤比例及出现并发症比例均高于对照组患者(P0.05);死亡率对比两组差异不明显(P0.05);多因素回归分析发现:高龄、住院时间长、转科、出院科别为内科、患肿瘤和出现并发症均是影响到歧义病案出现的危险因素(P0.05)。结论歧义病案的产生与年龄、住院时间、转科、出院科别、患肿瘤和出现并发症密切相关,医院病案管理可根据歧义病案产生的危险因素制定相应的防治对策,加强病案质量管理。     

The Hispanic Americans Baseline Alcohol Survey (HABLAS): Predictors of Alcohol Attitudes and Expectancies in Hispanic National Groups

Background: Multiple theoretical frameworks identify attitudes and expectancies as important predictors of alcohol behavior. Few studies have examined demographic predictors of these evaluative and belief‐based cognitive mediators in the general population, and none have examined them in large‐scale studies of Hispanics, a group at higher risk for drinking behavior and problems. This study probes the extent to which dimensions of attitudes and expectancies share common demographic predictors in a large sample of Puerto Ricans, Cuban‐Americans, Mexican‐Americans, and South/Central Americans. Methods: The 2006 Hispanic Americans Baseline Alcohol Survey (HABLAS) used a multistage cluster sample design to interview 5,224 individuals randomly selected from households in Miami, New York, Philadelphia, Houston, and Los Angeles. This study focused on 2,773 respondents self‐identified as current drinkers. Multiple linear regression was used to identify predictors of positive and negative dimensions of attitudes and expectancies, controlling for various background variables. Results: Religious affiliation selectively predicted alcohol attitudes, with Catholics having more positive and fewer negative attitudes than other religious groups. Hispanic group selectively predicted alcohol expectancies, with Cuban‐Americans having less positive and less negative expectancies than other groups. Being U.S.‐born or male predicted more positive attitudes and expectancies, but birthplace and gender did not predict negative dimensions of attitudes or expectancies. Higher acculturation and more education were linked to a decreased tendency to agree with any item. Age was positively and negatively associated with negative expectancies and positive attitudes, respectively, and having never been married, higher income, and unemployment were each linked to fewer negative attitudes. Conclusions: Although there is some overlap, attitudes and expectancies are influenced by different sociodemographic variables. Positive and negative dimensions of those constructs also show distinct patterns of relations. Prevention and treatment programs targeting cognitive mediators of behavior should be mindful of these differential determinants and future modeling endeavors should incorporate them.     

Alpha power is influenced by performance errors

Error commission evokes changes in event-related potentials, autonomic nervous system activity, and behavior, presumably reflecting the operation of a cognitive control network. Here we test the hypothesis that errors lead to increased cortical arousal, measurable as changes in electroencephalogram (EEG) alpha band power. Participants performed a Stroop task while EEG was recorded. Following correct responses, alpha power increased and then decreased in a quadratic pattern, implying transient mental disengagement during the intertrial interval. This trend was absent following errors, which elicited significantly less alpha power than correct trials. Moreover, post-error alpha power was a better predictor of individual differences in post-error slowing than the error-related negativity (ERN), whereas the ERN was a better predictor of post-error accuracy than alpha power. These findings imply that changes in cortical arousal play a unique role in modulating post-error behavior.     

突发事件特勤应急部队人群的应对方式及其影响因素研究

目的研究特勤应急部队人群应对突发事件方式的特点及影响因素。方法从重庆市武警和公安消防部队整群抽取12个特勤中队，对其应对突发事件的方式及影响变量进行现况调查，比较其应对方式与军人常模的差异，评价其表现类型和成熟程度，并筛选主要影响因子。结果纳入的396例受试者中，86．36％具有突发事件任务的经历，各项应对因子平均水平与军人常模相比，差异有统计学意义（P≤O．01），整体应对行为模式为成熟型；应对行为类型与得分达标情况相关（P〈0．001），但列联系数偏低（C=0．23），显示应对方式成熟程度仍有限。从影响变量的作用效应来看：自信心不足、自我与经验不和谐、自我刻板性和缺乏危机生存技能是影响应对方式的负性因素，而社会支持、自我灵活性、责任心、任务经历是正性因素。其中，支持利用度、经验不和谐、自信心程度、逃生知识对不同应对行为的影响比较普遍，而其余因素的影响比较单一。结论特勤应急部队人群应对突发事件的方式总体上比较成熟稳定，但个体差异较大，并受多种因素影响，故有必要开展针对性的干预训练，进一步提高特定人群应对方式的成熟程度。