基于病案首页分析的中医医院单病种质量评价研究

Research on Quality Evaluation of a Single Sort Disease in Traditional Chinese Medicine Hospital Based on the Analysis of Home Page of Medical Record

目的探索基于病案首页数据分析的中医特色单病种质量管理评价方案。方法收集上海市某三级甲等中医医院中医特色单病种腰椎间盘突出症的病案首页数据,分析病种2631份病案首页的住院总费用(不包含材料费)、住院日、日均住院费用、中医治疗费用等相关指标。结果腰椎间盘突出症患者住院各项相关指标之间均存在相关性(P<0.01);相关指标在不同年龄段、性别、治疗类别以及治疗方式间比较,差异有统计学意义(P<0.01)。通过分析相关指标置信区间外的病历,发现诊疗过程中存在术前医嘱执行不到位、术后康复治疗异于常规诊疗方案等质量问题。结论通过对腰椎间盘突出症病案首页数据进行挖掘分析,可以明确相关住院指标之间的关系并设定指标置信区间,形成快速聚焦定位可能存在质量异常病例的方法,进而对病种质量进行评价和管理。

Objective To explore the management quality evaluation of a single sort of disease in traditional Chinese medicine hospital based on the analysis of home page of medical record.Methods Home page data of medical records of patients with lumbar disc herniation in a GradeⅢLevel A traditional Chinese medicine hospital in Shanghai were collected.The total hospitalization cost(material costs were excluded),length of stay,average daily hospitalization cost and Chinese medicine treatment cost and other relevant indicators of 2631 medical records were analyzed.Results The related indicators of the medical records of patients with lumbar disc herniation showed a significant correlation among the relevant indicators of hospitalization(P<0.01).Significant differences in relevant indicators were detected in patients with different ages,genders,treatment category and treatment methods(P<0.01).By analyzing the medical record with relevant indicators outside the confidence interval,quality problems in the diagnosis and treatment process were detected,such as incomplete execution of preoperative medical advice and postoperative rehabilitation treatment different from routine treatment.Conclusion Through the mining and analysis of home page data of medical records of patients with lumbar disc herniation,the relationship among the relevant hospitalization indicators can be clarified and the confidence interval of the indicators can be set,to form a method to quickly focus and locate the possible causes of abnormal quality,and then to evaluate and manage the quality of the disease.