病案首页质量与DRGS实施

DRGs付费标准依据病案首页内容而制订。目前病案首页填写存在着患者信息采集不完整、不准确;主要诊断及出院情况选择错误;手术、操作填写不规范;以及疾病和手术操作分类错误等问题,这些不同程度地影响DRGs付费的正确实施,影响医保部门对医院的合理付费。通过强化医务人员的责任心及质量意识、发挥相关部门的职能监督作用、完善和提高计算机系统的监控力度、健全沟通反馈制度、培养满足病案信息化管理的综合型人才等措施,能实现病案首页的规范填写,积极应对DRGs付费的需要。     

Cerebrovascular disease as a general medicine discharge diagnosis: assessment of diagnostic agreement on case note review

Background: Accurate clerical coding of discharge diagnoses is important partly because results may be used to derive a recommended costing for hospital length of stays (LOS). Some authors think that discharge coding undertaken by clinicians will result in less diagnostic misclassification than clerical coding. This presupposes a high degree of between-observer diagnostic agreement between clinicians. Aims: To compare discharge coding undertaken by two general physicians, for patients receiving a clerical discharge code of cerebrovascular disease. The recommended LOS was then calculated from each observer's discharge codes using the Physicians Diagnosis Related Group Working Guidebook. Results: Eighty-two cases were coded as stroke by the clerical coder. Both medical coders agreed with this diagnosis in 68 (83%) of these cases. The corresponding figure for cases coded by the clerical coder as transient cerebral ischaemia was 47% (32/68) agreement between all three observers. Correcting for chance agreement between medical observers using the kappa statistic, a value of 0.64 was obtained for the combined stroke and transient cerebral ischaemia discharges, suggesting moderate diagnostic agreement. Using the clerical coder's results, the mean recommended LOS for all cases of cerebrovascular disease over the study period was calculated at 6.68 days. The corresponding values for the two medical coders were 6.68 days and 6.75 days. Conclusions: Diagnostic agreement between clinicians was moderate. Consideration of alternative diagnostic possibilities and the difficulty in determining the duration of neurological deficit were the main reasons for diagnostic disagreement. The mean recommended LOS was similar, however, when comparing results from all three observers.     

基于波士顿矩阵对2017-2019年某三级综合医院科室抗菌药物使用强度的评价

摘要：目的 基于三级综合医院抗菌药物使用强度(defined daily dose,DDD管控的现存问题,引入CMI指数并基于波士顿 矩阵模型试图从医院层面为科室DDD管控做出迅速评价和判断。方法 绘制波士顿矩阵,分别以CMI指数、DDD值作为横、纵 坐标,确定界值和焦点,以各科室的CMI、DDD值作为坐标,得到波士顿矩阵图。结果 28个科室中7个科室(大部分为手术科 室)分布在第II象限(严管区)、5个科室分布于第I象限(放任区)、7个科室分布于第IV象限(表扬区)、其他科室分布于第III象限(鼓 励区)。结论 运用波士顿矩阵模型管理DDD,通过放任区、严管区、鼓励区及表扬区分别予以不同管理策略,为抗菌药物重 点管控提供线索,节约医院管理成本,同时强调动态管理,旨在推动变化,以奖代罚,促进良性循环。     

阑尾炎疾病诊断相关分组细分组研究

探讨阑尾炎病种基本组到DRGs组的细分组方法,为成都市的DRGs体系建立提供参考,合理控制医疗费用的增长。方法利用SPSS 19.0统计软件对2015年-2016年成都市某三级甲等医院阑尾炎住院患者费用明细数据进行多元回归及决策树分析,完成病种DRGs细分组的划分。结果从影响费用的多种因素出发,首先利用手术操作作为分层变量,完成基本DRGs分组,再利用年龄及合并症并发症严重程度两个因素,完成DRGs细分组结果,确定每个细分组的合理费用区间。结论通过DRGs细分组划分结果,指导医疗保险基金支付方式的改革,并在一定程度上促进医疗机构服务能力和效率及医疗质量的提升     

医改政策对医院住院费用的影响分析

目的分析医改后住院患者费用和基金使用等方面的变化,为医院实施DRGs费用精细化管理提供建议。方法借助DRGs管理工具和Excel工具对医院2017年4月-6月份出院病例与2016年同期病例进行多维度回顾性分析。结果住院患者费用结构发生变化,药品费用下降明显,耗材和服务类费用同比上涨,生育和超转人员基金使用总量增幅均在10%以上。结论医院医改已初见成效,但需进一步调整医院DRGs病组结构,对内科、外科、非手术操作组下DRGs病组费用实施针对性精细化管理,加强医用耗材的管控力度     

基于DRGs的病案首页质量分析

目的分析内蒙古自治区3家医院2016年病案首页数据质量缺陷。方法3家医院共抽查病历300份,对病案首页数据错误进行统计分析。结果主要诊断、其他诊断填写正确率分别为74%、71%,主要手术操作、其他手术操作填写正确率分别为87%、58%,主要诊断、其他诊断编码正确率分别为94%、89%;主要手术操作、其他手术操作编码正确率分别为85%、53%。结论通过分析病案首页数据错误,持续改进病案首页质量。     

基于DRGs的某医院新生儿科医疗业务评价

目的　分析某医院新生儿科出院病人DRGs分组情况,评价医疗组住院服务指标,为DRGs病组优化、医院精细化管理提供依据。方法　以2015-2016年新生儿科7189例出院患者作为研究对象,对病案数据和DRGs分组资料进行收集分析。结果　出生天数为1~5天的患者占总研究对象的69.37%,低出生体重儿约占33.58%;对纳入病例进行DRGs分组,足月产（体重>2499g）伴严重问题（PU11）组入组患者最多,约占46.15%,其次是早产儿（体重1500~2499g)伴严重问题（PT11）组,约占21.34%;对医疗组进行DRGs指标分析,A、B组入组例数较多,病种覆盖面广,总权重较大,C组CMI值最高,两年分别为3.30和3.29。结论　该院新生儿科收治患者较严重,医疗技术难度较大,医疗组收治情况各异,引入DRGs指标可以客观公平的评价科室工作强度、医疗难度以及医疗消耗等情况。     

Differences in the Implementation of Diagnosis-Related Groups across Clinical Departments: A German Hospital Case Study

Objective. This article aims to examine the implementation process of diagnosis-related groups (DRGs) in the clinical departments of a German hospital group and to explain why some gain competitive advantage while others do not.
Study Setting. To investigate this research question, we conducted a qualitative study based on primary data obtained in six clinical departments in a German hospital group between 2003 and 2005.
Study Design. We chose the case study method in order to gain deep insights into the process dynamics of the implementation of DRGs in the six clinical departments. The dynamic capability approach is used as a theoretical foundation. Employing theory-driven categories we focused on idiosyncratic and common patterns of "successful coders" and "unsuccessful coders."
Data Collection. To observe the implementation process of DRGs, we conducted 43 semistructured interviews with key persons, carried out direct observations of the monthly meetings of the DRG project group, and sampled written materials.
Principal Findings. "Successful coders" invest into change resources, demonstrate a high level of acceptance of innovations, and organize effective processes of coordination and learning.
Conclusions. All clinical departments only put an emphasis on the coding aspects of the DRGs. There is a lack of vision regarding the optimization of patient treatment processes and specialization. Physicians are the most important key actors, rather than the main barriers.     

从院间差异探讨DRGs试行的问题及对策

目的回顾性的研究院间差异对同组DRGs住院费用的影响，分析原因，探讨对策。方法北京地区三家三级甲等医院2002年至2005年病案首页数据库，按DRGs分组后，选取样本量大、主要诊断相对明确的组别共五组。运用方差分析及LSD检验、卡方检验，分析相同组别在不同医院间医疗费用、住院日的差异。结果院间差异显著（P〈0．05）。结论没有统一的临床路径是造成院间差异的主要原因。     

Appraisal and cytomorphologic analysis of common carcinomas of the breast

This work is based on 15 years experience with more than 9000 needle aspiration biopsies from the breast performed by a number of clinicians without syringe guns. From 1981 through 1983, 329 carcinomas were detected with a sensitivity of 90%. A positive or suspicious report was issued in 17 of the 32 minimal carcinomas. There were no false-positive diagnoses. A retrospective comparative study was made on the aspiration biopsy cytology specimens from 65 histologically verified carcinomas: 30 infiltrating ductal, 16 infiltrating lobular, 10 medullary, and 10 colloid carcinomas. Parameters included the pattern, major malignant criteria, and cell measurements by calibrated ocular micrometry. The classic features of each carcinoma and the differential cytomorphology are described.