应用病例分型评价医疗费用和住院日

目的探讨以病例分型为基础的质量费用管理方式,用于分析同一病种不同病情的患者所花费的医疗费用和住院日之间的差别。方法对呼吸内科751例和综合内科776例肺部感染患者进行病例分型,分别统计A、B、C、D型的医疗费用和住院日。结果不同分型患者之间医疗费用和住院日都有显著性差异;呼吸内科A、C型医疗费用和C型住院日较综合内科少,差异有统计学意义;综合内科C型率较呼吸内科高,呼吸内科D型率较综合内科高,P〈0．001。结论应用病例分型有助于科学控制和合理评价患者医疗费用高低和住院日长短,也为真实反映不同医疗单位的诊疗质量和效率提供客观的依据。     

临床路径在单病种费用中的应用分析

【目的】探索临床路径（CP）在单病种费用中的应用价值。【方法】采用回顾性分析与分层随机抽样的方法,将临床CP组与非CP单病种（对照组）的病种费用、平均住院日、药品比率综合比较。【结果】CP组次均住院费用、平均住院日及药费比率等指标均较对照组显著下降（P〈0．01,P〈0．05）。【结论】CP通过规范诊疗行为,有效地降低整体医疗费用、控制了不合理医疗费用,临床路径作为单病种付费标准更具有合理性、科学性。     

在医疗质量和医疗费用博弈中医院医保管理要点探讨

目的探讨在医疗质量和医疗费用博弈中医院医保管理要点。方法医院医保管理部门作为定点医院医保工作的管理者和医疗保险政策的推行者,通过与医疗保险机构以及医院临床科室的协商和配合,在积极探索合理的医保政策的同时严格监督医保政策在医院执行情况。结果明确了建立合理的沟通机制和谈判机制、做好临床科室宣传工作等医院医保管理要点,有助于提高管理效率,有益于保证医疗质量和控制医疗费用。结论医保管理在医院管理中的重要地位逐步彰显,医院医保管理部门必须狠抓管理要点,充分发挥医保科的职能作用,有效促进医、保、患的和谐发展。     

桡骨头半脱位单病种费用对比分析

桡骨头半脱位(Nursemaid’s elbow or annular ligament displacement，ALD)是常见的／小儿科急诊，多见于1～4岁的儿童。此类急诊处理较简单，使用手法复位即可取得较好的治疗效果，但由于以往没有急诊专业的医师，处理上差别较大，也造成了该疾病在急诊科的单病种费用差别较大。我院急诊科2001年1月～2004年3月共诊治127例桡骨头半脱位病例，我们对比了由急诊专科医师处理与急诊轮转医师处理的桡骨头半脱位单病种费用情况，现报告如下：     

680例SARS临床确诊患者医疗费用和影响因素分析

目的 分析680例SARS临床确诊患的医疗费用及影响因素和典型药物的费用-效果，为临床医生和政府提供决策依据。方法 设计回顾性队列研究，比较重症型和普通型患在有、无基础疾病间的医疗费用及药品费用差异，分析影响因素。选择三种典型用药，比较其临床有效性和费用-效果。结果 重症型治愈率低于普通型治愈率(73．68%，99．38％，P=0．000)；普通型有基础疾病患治愈率低于无基础病患(96％，99．66％，P=0．00l6)，重症型患治愈率组内无统计学差异。两型患平均住院日组内比较无统计学差异；有基础疾病和无基础疾病的普通型患其医疗费用分别为7879．22和7172．23元/人，重症型患为24912．89和26433．53元/人，组内比较均无统计学差异；患年龄和病情均与医疗费用相关，y=4585．7l 79．04X1 17188．87X2；有基础疾病和无基础疾病重症型患使用中小剂量甲基强的松龙比较，医疗费用和临床效果无统计学差异；使用和不使用病毒唑的普通型无基础疾病患，其费用-效果比为6107和4225元；使用和不使用胸腺肽的无基础疾病普通型患费用-效果比分别为11651和6107元。结论 有基础疾病的普通型患治愈率低于无基础疾病；费用高低与患年龄和病情严重程度有关，病情越重，年龄越高，费用越高。药品费用占医疗费用比例最大；中小剂量激素在有基础疾病和无基础疾病重症型患的治愈率和费用无统计学差异；在无基础疾病的普通型患中使用和未使用胸腺肽的治愈率无统计学差异，但使用胸腺肽将增加人均医疗费用5877元。在无基础疾病的普通型患中使用和未使用病毒唑的治愈率一致，但使用病毒唑将增加人均医疗费用l882元。     

医疗费用支付方式利弊分析

本文对五种常用医疗费用支付方式对激励及约束医疗服务提供者的行为、控制医疗费用、调节医疗资源配置、促进医疗质量提高等方面的不同作用进行了比较分析，作者认为采用适合当地情况，以单元付费、人头付费、病种付费、总额预算等多种付费方式并存的复合式支付方式可实现医、保、患三方共赢的目的，将是今后研究、发展的方向。     

影响医疗费用质量的因素与对策

医疗费用质量越来越受到各方的关注 ,费用的合理性、公开性、准确性以及病人对费用的隐含需求和一些非人为因素都是影响医疗费用质量的重要因素。只有提高医务人员对医疗质量经济性的认识 ,最大程度地满足患者的“隐含需求” ;充分发挥网络优势 ,规范医务人员的服务行为 ;加强医疗收费的动态监测 ,不断提高医疗服务质量才能最大限度地提高医疗费用质量 ,医院才能在医疗市场竞争中站稳脚跟     

恶性肿瘤患者住院医疗费用分析

【目的】了解恶性肿瘤患者平均住院医疗费用、构成情况及影响因素,为有效控制医疗费用,合理利用卫生资源提供参考依据。【方法】对韶关市粤北人民医院恶性肿瘤住院患者(6 229例)的住院费用及影响因素进行分析。【结果】平均住院医疗费用为13 895元/人次;住院收费项目构成比中药费占的比例最大;住院医疗费用与病种、平均住院日、治疗手段、费用支付来源有关。【结论】恶性肿瘤住院费用昂贵,需采取综合措施控制住院费用,充分合理利用卫生资源。     

加强医疗费用管理与降低医疗费用体会

随着医疗体制的不断深化，医疗服务收费日渐成为人民群众的热点问题。近几年，我院在医疗服务价格管理方面始终坚持以患者为中心，把物价管理作为医院管理的重要内容。从而规范医疗收费行为，取得了良好的社会和经济效益。     

新型冠状病毒肺炎疫情防控期间北京协和医院互联网线上诊疗成本分析

目的初步评估北京协和医院在新型冠状病毒肺炎疫情防控期间提供互联网线上诊疗服务的成本效果。方法回顾性收集并分析2020年2月10日至4月15日北京协和医院互联网线上诊疗服务试运行期间,所有接受线上门诊问诊的患者临床资料。选取社会立场角度,采用决策树法比较互联网线上诊疗的成本效果,结果以增量成本效果比表示。采用单因素分析法分析模型的敏感性。结果互联网线上诊疗系统试运行47 d内,线上接诊发热问诊3055人次、2070例患者,平均可减少线下发热门诊就诊约44例/d,约为疫情高峰期发热门诊日均实际接诊量的1/4;接诊非发热相关问诊36 549人次、20 467例患者,平均可减少线下非发热门诊就诊约435例/d,约为疫情高峰期门诊日均总量的1/5。以实际线上诊疗免问诊费计算,增量成本效果比为-64.7元/人次问诊。如按门诊医事服务费水平估算每例问诊的实际成本,则最终增量成本效果比为-5.5元/人次问诊。敏感性分析结果表明,患者往来交通费用、误工费以及互联网线上诊疗解决问题有效率是影响增量成本效果的主要因素。结论新型冠状病毒肺炎疫情期间,北京协和医院提供的互联网线上诊疗服务不仅有效配合了政府防疫政策执行,同时可节约患者的经济成本,为优化医疗卫生服务提供了解决思路。     

Attributable Hospital Cost and Length of Stay Associated with Health Care-Associated Infections Caused by Antibiotic-Resistant Gram-Negative Bacteria

Determination of the attributable hospital cost and length of stay (LOS) are of critical importance for patients, providers, and payers who must make rational and informed decisions about patient care and the allocation of resources. The objective of the present study was to determine the additional total hospital cost and LOS attributable to health care-associated infections (HAIs) caused by antibiotic-resistant, gram-negative (GN) pathogens. A single-center, retrospective, observational comparative cohort study was performed. The study involved 662 patients admitted from 2000 to 2008 who developed HAIs caused by one of following pathogens: Acinetobacter spp., Enterobacter spp., Escherichia coli, Klebsiella spp., or Pseudomonas spp. The attributable total hospital cost and LOS for HAIs caused by antibiotic-resistant GN pathogens were determined by comparison with the hospital costs and LOS for a control group with HAIs due to antibiotic-susceptible GN pathogens. Statistical analyses were conducted by using univariate and multivariate analyses. Twenty-nine percent of the HAIs were caused by resistant GN pathogens, and almost 16% involved a multidrug-resistant GN pathogen. The additional total hospital cost and LOS attributable to antibiotic-resistant HAIs caused by GN pathogens were 29.3% (P < 0.0001; 95% confidence interval, 16.23 to 42.35) and 23.8% (P = 0.0003; 95% confidence interval, 11.01 to 36.56) higher than those attributable to HAIs caused by antibiotic-susceptible GN pathogens, respectively. Significant covariates in the multivariate analysis were age ≥12 years, pneumonia, intensive care unit stay, and neutropenia. HAIs caused by antibiotic-resistant GN pathogens were associated with significantly higher total hospital costs and increased LOSs compared to those caused by their susceptible counterparts. This information should be used to assess the potential cost-efficacy of interventions aimed at the prevention of such infections.During the last few decades, the increasing rates of resistance among common bacterial pathogens have become a major threat to human health (1, 14, 18, 32, 34, 38). Research involved with the development of new antibiotics has not progressed in parallel with the increasing rates of resistance, which leaves clinicians with fewer options for the treatment of some infections (1, 39). Infections caused by antibiotic-resistant bacteria are believed to result in higher mortality rates, longer durations of hospital stays, and higher health care costs compared to those that result from infections with their antibiotic-susceptible counterparts (16). Over 50% of health care-associated infections (HAIs) are caused by resistant strains (18). The trends of increasing resistance are most critical in intensive care unit (ICU) patients, a population extremely susceptible to HAIs (5, 25). Although gram-negative (GN) bacteria comprise the major source of HAIs, the main focus of recent research and development has been on resistant gram-positive multidrug-resistant (MDR) organisms, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci (3, 9, 11). The GN bacteria causing HAIs are mainly Klebsiella spp., Pseudomonas aeruginosa, Acinetobacter baumannii, and Escherichia coli (14). All of these organisms, as well as Enterobacter spp., have been shown to have increasing rates of resistance (14, 30, 33), and MDR within these bacteria is becoming a problem (31, 40). The incidence of HAIs caused by the resistant pathogens Pseudomonas aeruginosa and A. baumannii are high and are a cause for concern (14).HAIs are one of the most serious patient safety issues in health care today; indeed, they are the fifth leading cause of death in acute-care hospitals (20). Between 5% and 15% of hospital inpatients develop an infection during their admission, and critically ill, ICU patients are 5 to 10 times more likely to acquire an HAI than those in general wards. In the United States, approximately 2 million people per year acquire a bacterial infection while they are in the hospital. Of these, 50 to 70% are caused by antimicrobial-resistant strains of bacteria and 77,000 to 90,000 infected patients die. Prior research has shown that antibiotic resistance, in general, leads to additional costs, lengths of stay (LOSs), morbidity, and mortality, presumably as a result of inappropriate or suboptimal therapy (8). Although it is known that HAIs due to resistant GN bacteria, in particular, have been associated with negative patient outcomes, the additional cost associated with infections with these pathogens has not been fully elucidated. In 2002, the Centers for Disease Control and Prevention conducted a systematic audit to investigate economic evidence linking HAIs caused by resistant bacteria with increased costs. The attributable cost of HAIs, in general, was estimated to be $13,973 (42), but interpretation of the findings of the studies considered was difficult because of various methodological issues.Studies that appropriately assess attributable costs could further clarify the financial burden of HAIs caused by antibiotic-resistant bacteria and thus enable decision makers to weigh and justify the allocation of resources to control this growing problem. Some studies have been designed to clarify the financial impact of nosocomial infections caused by drug-resistant GN pathogens (4, 7, 12, 13, 21-24, 36), but the studies'' scope and methods varied widely. Therefore, the goal of the retrospective investigation described here was to appropriately determine the extra cost and LOS attributable to HAIs caused by resistant GN pathogens compared to the cost and LOS of infections caused by their susceptible counterparts at the Medical University of South Carolina hospital in Charleston, SC. The study was approved by the university''s Institutional Review Board.     

新生儿医院感染分析及对策

目的　探讨新生儿医院感染情况。方法　分别对我院新生儿室 1 999- 0 1～ 1 999- 1 2入院的 472例新生和2 0 0 0～ 2 0 0 1 - 0 2入院的 446例新生儿进行回顾性调查分析 ,并在调查过程中逐渐给予恰当的监控措施。结果　 1 999年住院的 472例新生儿中发生医院感染 41例 ,感染率 9% ;2 0 0 0～ 2 0 0 1 - 0 2入院的 446例新生儿中 ,发生医院感染 2 4例 ,感染率 5.4% ,感染部位多为呼吸道、消化道、泌尿道、皮肤粘膜。感染病原菌主要是金黄色葡萄球菌、表皮葡萄球菌、大肠杆菌、白色链珠菌。结论　提高医院感染管理意识 ,建立健全规章制度 ,严格消毒隔离管理 ,是预防新生儿医院感染的关键。     

Cost and Length of Hospital Stay: Comparisons Between Nonthoracotomy and Epicardial Techniques in Patients Receiving Implantable Cardioverter Defibrillators

Twenty-five patients with implantable Cardioverter defibrillators (ICDs) implanted intrathoracically (group I) were compared with 25 patients who underwent implant using the nonthoracotomy approach (group II). AH systems were implanted by the same medical team, in the same high volume implanting center. Indications for implantation were comparable in both groups. Patient characteristics were not statistically different with the exception of age fee-group I vs 71-group II; P < 0.05). Although left ventricular ejection fractions appeared to differ (32% vs 37%, respectively), this difference was not statistically significant (P = 0.06). ICD models used in group I were: Ventritex Cadence (16), Telectronics Guardian 4211 (2), Medtronic PCD (7); in group II they were: Ventritex Cadence (15), Guardian 4211 (2), and CPI 1600 (1). Total length of hospital stay was 16 ± 6 days for group I versus 12 ± 5 for group II (P < 0.05). Number of postoperative days in an intensive care unit was 3.2 ± 2.8 for group I versus 0.5 ± 0.6 for group II (P < 0.0001). Postoperative length of stay was 8.2 ± 3.1 for group I versus 5.7 ± 4.4 for group II (P < 0.001). Mean total hospital charges for the entire length of stay were $72,918 ±$26,770 in group I versus $55,031 ±$42,870 in group II, representing a mean reduction of 21 % in global costs for group II patients. These data confirm that nonthoracotomy ICD implantation in an experienced center is associated with significantly shorter hospital stays, a virtual elimination of the need for postoperative intensive care, and globally lower total hospital costs. In addition, the presence of a statistically older population in group II does not negate these beneficial effects.     

Validation of Length of Hospital Stay as a Surrogate Measure for Injury Severity and Resource Use Among Injury Survivors

Objectives: While hospital length of stay (LOS) has been used as a surrogate injury outcome when more detailed outcomes are unavailable, it has not been validated. This project sought to validate LOS as a proxy measure of injury severity and resource use in heterogeneous injury populations. Methods: This observational study used four retrospective cohorts: patients presenting to 339 California emergency departments (EDs) with a primary International Classification of Diseases, Ninth Revision (ICD‐9), injury diagnosis (years 2005–2006); California hospital injury admissions (a subset of the ED population); trauma patients presenting to 48 Oregon EDs (years 1998–2003); and injured Medicare patients admitted to 171 Oregon and Washington hospitals (years 2001–2002). In‐hospital deaths were excluded, as they represent adverse outcomes regardless of LOS. Duration of hospital stay was defined as the number of days from ED admission to hospital discharge. The primary composite outcome (dichotomous) was serious injury (Injury Severity Score [ISS] ≥ 16 or ICD‐9 ISS ≤ 0.90) or resource use (major surgery, blood transfusion, or prolonged ventilation). The discriminatory accuracy of LOS for identifying the composite outcome was evaluated using receiver operating characteristic (ROC) analysis. Analyses were also stratified by age (0–14, 15–64, and ≥65 years), hospital type, and hospital annual admission volume. Results: The four cohorts included 3,989,409 California ED injury visits (including admissions), 236,639 California injury admissions, 23,817 Oregon trauma patients, and 30,804 Medicare injury admissions. Composite outcome rates for the four cohorts were 2.1%, 29%, 27%, and 22%, respectively. Areas under the ROC curves for overall LOS were 0.88 (California ED), 0.74 (California admissions), 0.82 (Oregon trauma patients), and 0.68 (Medicare patients). In general, the discriminatory value of LOS was highest among children, tertiary trauma centers, and higher volume hospitals, although this finding differed by the injury population and outcome assessed. Conclusions: Hospital LOS may be a reasonable proxy for serious injury and resource use among injury survivors when more detailed outcomes are unavailable, although the discriminatory value differs by age and the injury population being studied. ACADEMIC EMERGENCY MEDICINE 2010; 17:142–150 © 2010 by the Society for Academic Emergency Medicine     

护理人员对医疗责任保险的认知现状分析及对策

目的 了解护理人员对医疗责任保险的认知现状及影响医疗责任保险推广的原因。方法 采用单纯随机抽样方法,抽取20多个临床科室的护理人员及非临床科室护理人员180名,应用自行设计的问卷进行调查。统计学处理采用SPSS 10．0统计软件进行两独立样本的秩和检验。结果 护理人员的保险意识比较高,但投保率低。临床与非临床护理工作者在投保额与赔偿限额方面无显著性差异（P〉0．05）。结论 医疗责任保险制度有待完善,相关专业人才缺乏,应尽快发展完善,以适应市场需要。     

北京协和医院17种国家医保谈判抗癌药临床应用情况调查

  目的  了解国家卫生行政部门发布17种国家医保谈判抗癌药相关政策前后,北京协和医院相关药品的临床应用情况及变化趋势,以期为医院药品目录优化与调整提供参考。  方法  收集并分析2017年12月1日至2019年11月30日(2017年12月1日至2018年11月30日为2018年度,2018年12月1日至2019年11月30日为2019年度)北京协和医院17种抗癌药的全部门诊及住院处方数据。对患者基本信息、用药数量、用药金额、用药频度、限定日费用等进行统计分析。  结果  2019年度共6881例患者使用此17种抗癌药。其中,门诊患者4713例(68.5%),住院患者2168例(31.5%)。17种抗癌药用药金额占本院全部抗癌药用药金额、全部药品用药金额的比率分别为16.3%和3.8%;用药金额排名前3位的病种分别为胸部肿瘤、血液肿瘤和泌尿系统肿瘤; 用药金额排名前3位的药物分别为奥希替尼、奥曲肽微球、克唑替尼,且用药金额与用药频度同步性好; 限定日费用排名前3位的药物分别为维莫非尼、西妥昔单抗和伊布替尼。政策实施前已入院的6种抗癌药中,2019年度用药金额和处方量分别同比增加78.2%、89.8%;用药金额占本院全部抗癌药用药金额、全部药品用药金额的比率分别同比增加54.4%、78.6%;与2018年度相比,2019年度奥希替尼用量与用药金额均大幅增加,西妥昔单抗、阿昔替尼、舒尼替尼及奥曲肽微球用量增加而用药金额下降,培门冬酶用量和用药金额均显著下降。  结论  国家医保谈判政策促进了17种抗癌药在临床的使用,提高了用药可及性,亦导致药品费用有较大幅度增加。应加强对相关药品的临床应用监测和动态评估,在保障患者用药需求的同时促进合理用药。     

重庆大坪医院脑梗死急性期住院费用的构成和预测

目的确定重庆大坪医院脑梗死病人急性期住院费用的构成比及其影响因子.方法收集311名在重庆大坪医院神经内科因急性脑梗死住院病人的人文资料、临床资料、住院费用、收费成本比,用逐步回归分析筛选影响住院费用的主要预测因素.结果平均住院天数14 d,平均住院费用6 130元.其中药品费占53.1%,床位费占7.9%,检查费占25.6%,其他治疗费占11.1%.住院费用的影响因子最主要的为NIHSS评分（NIHSS美国国立卫生院卒中评分量表）,其余为并发肺部感染、住院天数、住院2 w ADL评分（生活自理量表）.结论药品费可以说明大部分住院费用.住院费用主要影响因素为NIHSS评分、并发肺部感染、住院天数、住院2 w的ADL,其中NIHSS评分为住院费用最重要的影响因子.     

重庆大坪医院脑梗死急性期住院费用的构成和预测

目的确定重庆大坪医院脑梗死病人急性期住院费用的构成比及其影响因子.方法收集311名在重庆大坪医院神经内科因急性脑梗死住院病人的人文资料、临床资料、住院费用、收费成本比,用逐步回归分析筛选影响住院费用的主要预测因素.结果平均住院天数14 d,平均住院费用6 130元.其中药品费占53.1%,床位费占7.9%,检查费占25.6%,其他治疗费占11.1%.住院费用的影响因子最主要的为NIHSS评分(NIHSS美国国立卫生院卒中评分量表),其余为并发肺部感染、住院天数、住院2 w ADL评分(生活自理量表).结论药品费可以说明大部分住院费用.住院费用主要影响因素为NIHSS评分、并发肺部感染、住院天数、住院2 w的ADL,其中NIHSS评分为住院费用最重要的影响因子.