区域点数法总额预算下医疗机构“冲点”行为分析——以DIP支付方式为例

区域点数法总额预算作为一种预算控制方式,可与不同的支付单元付费方式结合,探究区域点数法总额预算下医疗机构“冲点”行为,有助于改善医保支付方式运行模式。本研究对区域点数法总额预算下医疗机构“冲点”行为情况进行梳理,运用博弈论揭示DIP支付方式下医疗机构的“冲点”行为选择。从理论与实践方面均证明区域点数法总额预算会带来医疗机构“冲点”行为风险。通过博弈模型可知,DIP支付方式中医疗机构的严格优势策略包含不合理医疗的各类“冲点”行为。不合理“冲点”行为的惩罚金额、医保经办机构的监管成本、不合理“冲点”行为的额外收入金额大小对医疗机构不合理“冲点”行为和医保经办机构监管到位程度产生影响。医保部门需要从优化支付、监管机制等实施模式着手,减少不合理“冲点”行为。     

天津地区汉族人群IL-10-592C/A基因多态性与冠状动脉支架术后再狭窄的关系

目的 探讨中国天津地区汉族人群白细胞介素-10(interleukin-10,IL-10)-592C/A基因多态性的功能性以及其对经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)术后再狭窄的发病,PCI术后血清IL-10水平的影响.方法 对437例接受PCI并进行冠状动脉造影随访的患者,按冠状动脉造影结果分为再狭窄组(166例)和非再狭窄组(271例),应用聚合酶链反应-限制性片段长度多态性方法检测IL-10-592位点基因型和等位基因频率的分布;用酶联免疫吸附试验法测定2组PCI术前及PCI术后24 h血清IL-10浓度,并比较两组间和各基因型间IL-10水平.结果 (1)IL-10-592C/A基因型和等位基因频率在再狭窄组和非再狭窄组之间差异无统计学意义(P均＞0.05);(2)PCI术后24 h血清IL-10水平再狭窄组显著低于非再狭窄组[(82.67±35.02)ng/Lvs.(95.08±32.26)ng/L,P＜0.05];(3)IL-10-592位点A等位基因携带者(AA+AC基因型)术后24 h血清IL-10水平明显低于非携带者(CC型)[(86.13±34.77)ng/L vs.(102.50±27.52)ng/L,P＜0.05];(4)再狭窄组A等位基因携带者术后24 h血清IL-10水平明显低于非携带者[(78.51±34.09)ng/L vs.(102.19±33.66)ng/L,P＜0.05];(5)再狭窄危险的多因素Logistie回归分析显示:急性冠状动脉综合征、术前狭窄程度、靶病变长度与冠状动脉内支架再狭窄呈正相关(()R值分别为5.90、1.86、2.83),术后24 h血清IL-10水平、参照血管直径、支架直径与冠状动脉内支架再狭窄呈负相关(OR值分别为0.99、0.70、0.46).结论 (1)IL-10基因-592 C/A多态性与中国天津地区汉族人群再狭窄发病无关;(2)IL-10是PCI术后早期的炎症细胞因子,术后24 h血清IL-10水平为再狭窄的独立预测因素,携带A等位基因的个体可能通过降低其表型血清IL-10水平而增加了冠状动脉内支架术后再狭窄的发病.

Abstract：

Objective To investigate the relationship of interleukin-10 gene (IL-10)polymorphism and the serum IL-10 level with restenosis after percutaneous coronary intervention (PCI) in Tianjin Chinese Han population and study the effect of IL-10 gene polymorphism on serum IL-10 level. Methods Four hundred and thirty-seven patients who successfully underwent PCI with a follow-up angiography were divided into a restenosis group (n= 166) and non-restenosis group (n= 271). The IL-10 gene promoter polymorphism at position -592 was determined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. Meanwhile their serum IL-10 level before and 24 h after PCI was determined by enzyme-linked immunosorbent assay (ELISA). Results (1) There was no significant difference in frequencies of -592 genotypes and alleles between the two groups (P＞0. 05); (2) The 24 hpost-PCI IL-10 serum level of restenosis group was significantly lower than that of the non-restenosis group [(82. 67±35. 02) ng/L vs. (95.08±32.26) ng/L, P＜0.05]; (3) The serum level of the A allele carriers (AA+AC) was significant lower than that of the CC carriers [(86.13±34.77) ng/L vs. (102. 50±27.52)ng/L,P＜0.05]; (4) In the restenosis group, the 24 h post-PCI serum level of IL-10 in the A allele carriers was also significantly lower than that in those without the A allele [(78.51 ± 34.09) ng/L vs. (102.19 ±33.66) ng/L, P＜ 0. 05]; (5) Logistic regression analysis revealed positive correlations between acute coronary syndrome patients, pre-PCI degree of stenosis, length of target stenosis lesion and restenosis (OR=5.90, 1.86, 2.83 respectively); and there were negative correlations between 24 h post-PCI serum level of IL-10, the stent diameter, the diameter of reference vessel before stent implantation and restenosis (OR=0. 99, 0. 70, 0. 46 respectively). Conclusion (1) TheIL-10 gene -592 C/A polymorphism was not associated with restenosis in the Tianjin Chinese Han population; (2) IL-10 is an early post-PCI inflammatory cytokine, 24 h post-PCI serum IL-10 level was an independent predictive factor for restenosis,the IL-10 A allele carriers may have increased incidence of in-stent restenosis (ISR) by reducing the serum IL-10 levels.     

浅述医源性疾病

医源性疾病的概念关于医源性疾病的概念,迄今各家意见不尽统一。一般是指在疾病防治过程中,由于医务人员的诊治措施不当所引起的一类疾病或加重原有的疾病,甚至导致死亡,均称谓“医源性疾病”。但不包括所谓“庸医杀人”和“巫医害人”等非正常医疗所造成的事故或意外。医源性疾病是一种古老疾病,是伴随着疾病的防治而发生的。公元前523年,即