Prevalence and predictors of hospitalization in Crohn's disease in a prospective population-based inception cohort from 2000-2012

AIM: To analyze the prevalence, length and predictors of hospitalization in the biological era in the populationbased inception cohort from Veszprem province.METHODS: Data of 331 incident Crohn's disease(CD) patients diagnosed between January 1, 2000 and December 31, 2010 were analyzed(median age at diagnosis: 28; IQR: 21-40 years). Both in- and outpatient records were collected and comprehensively reviewed.RESULTS: Probabilities of first CD-related hospitalization and re-hospitalization were 32.3%, 45.5%,53.7% and 13.6%, 23.9%, 29.8%, respectively after one, three and five years of follow-up in Kaplan-Meier analysis. First-year hospitalizations were related to diagnostic procedures(37%), surgery or disease activity(27% and 21%). Non-inflammatory disease behavior at diagnosis(HR = 1.32, P = 0.001) and perianal disease(HR = 1.47, P = 0.04) were associated with time to first CD-related hospitalization, while disease behavior change(HR = 2.38, P = 0.002) and need for steroids(HR = 3.14, P = 0.003) were associated with time to first re-hospitalization in multivariate analyses.Early CD-related hospitalization(within the year of diagnosis) was independently associated with need for immunosuppressives(OR = 2.08, P = 0.001) and need for surgeries(OR = 7.25, P < 0.001) during the disease course.CONCLUSION: Hospitalization and re-hospitalization rates are still high in this cohort, especially during the first-year after the diagnosis. Non-inflammatory disease behavior at diagnosis was identified as the pivotal predictive factor of both hospitalization and rehospitalization.

Computer-based simulative training system--a new approach to teaching pre-hospital trauma care

Objective:A computer-based STS(simulative training system) in providing pre-hospital trauma care at a disaster site was applied to teaching nursing students in the Second Military Medical University,China.This article reports on the teaching effectiveness of this system.Methods:Among 92 participants,46 were in the study group and 46 were in the 'control' group. Each student completed a multiple-choice quiz after completing 18 hours(six three-hour sessions) of the study module,and a score was recorded.The simulative training module was completed only by the study group;the 'control' group was assigned in-class discussions for the same amount of time covering the same content as the study group.The final course scores,which included both comprehensive and group task-based tests were compared between these two groups.The study used a descriptive and comparative approach for quantitative data analysis.Tests of independency between the multiple choice scores and the simulation scores were also performed.Finally,anonymous surveys were conducted.Results:The study group performed better than the 'control' group with a significantly higher average score for the group scenario task-based test score,and consequently the study group's final course score was significantly higher than the 'control' group.As per chi-square tests,no significant associations were found between the multiple choice scores and the simulated training scores.The final surveys showed students overwhelmingly agreed that STS training improved their knowledge and skills,their ability to recognize a potential critical event, and their initial response for trauma care at pre-hospital settings.The survey responses of the study group were noteworthy as they indicated that students recognized the importance of simulative training,appreciated the realism of the simulation,and were able to fight/adjust to the stressful feelings in order to focus on the task.Conclusion:Computer-based STS may be an effective teaching model to help students improve their capability in providing pre-hospital trauma care,and in their effectiveness in disaster response.

Reduced order observer based identification of base isolated buildings

The objective of this study is to identify system parameters from the recorded response of base isolated buildings,such as USC hospital building,during the 1994 Northridge earthquake.Full state measurements are not available for identification.Additionally,the response is nonlinear due to the yielding of the lead-rubber bearings.Two new approaches are presented in this paper to solve the aforementioned problems.First,a reduced order observer is used to estimate the unmeasured states.Second,a least squares technique with time segments is developed to identify the piece-wise linear system properties.The observer is used to estimate the initial conditions needed for the time segmented identification.A series of equivalent linear system parameters are identified in different time segments.It is shown that the change in system parameters,such as frequencies and damping ratios,due to nonlinear behavior of the lead-rubber bearings,are reliably estimated using the presented technique.It is shown that the response was reduced due to yielding of the lead-rubber bearings and period lengthening.

Rate of Inappropriate Imaging Utilization by the Emergency Department in Community Hospitals

Objective: To retrospectively analyse the use of imaging studies in the Emergency Department of community hospitals using evidence based guidelines and clinical judgement. Methods: Medical records of 661 patients who visited the Emergency Department (ED) in 2015 and underwent imaging studies were reviewed. The Canadian Association of Radiologists, American College of Radiologists and Choosing Wisely Canada guidelines were used to determine the appropriateness of imaging studies. The use of prior patient imaging, the rate at which studies were repeated and the respective impacts on patient management of the imaging studies were also examined. Results: Of the 1056 imaging studies reviewed, 228 (22%) were found to be clinical situations where no imaging study was indicated while 168 (16%) were considered a suboptimal choice of imaging study or modality. When no study was recommended, a positive impact on the diagnosis was noted in 105 (46%) cases and on patient management 83 (36%) times. Notably, 219 (21%) patients had a relevant examination performed in the last 30 days, and 147 (14%) reports noted that the results of the prior study also concurred with the imaging study evaluated. Conclusion: In this study, 228 (22%) radiographs and CT studies, excluding MVC related imaging and extremity imaging, were not indicated based on appropriateness criteria and consequently had a limited impact on patient management. This supports the need for increased clinical decision support for ED physicians, regional health information exchanges and consideration of Computerized Physician Order Entry in the ED with embedded appropriateness criteria at the point of ordering.

人工关节集采对DRG IC29组病例住院费用的影响分析

[目的]研究集中带量采购对人工关节置换术患者住院费用的影响,为深化高值耗材持续改革提供依据。[方法]收集某三级医院集采前后DRG分组IC29组病例的DRG结算数据和医保信息系统的相关信息,进行倾向得分匹配后,采用描述性分析、非参数检验、结构变动度进行费用变化分析。[结果]集采政策实施后的各项费用中位数显示,IC29组病例次均费用下降了33445元,其中材料费下降了34835元;DRG统筹金额下降了13705元,个人自付金额下降了24550元。集采前后的结构变动度为60.52%,材料费呈负向变动,医疗服务费、检查化验费、药品费及其他费呈正向变动。结构变动贡献率前三位为材料费50.00%、医疗服务费26.04%、检查化验费16.36%。[结论]集采后IC29组病例的次均费用、材料费、医保支付和个人负担费用均明显降低,费用结构得到优化,人工关节集中带量采购成效明显。建议持续进行高值耗材集采工作,并协同推进医疗服务价格和医院薪酬制度等其他医改配套政策。

基于医院登记的78046例恶性肿瘤患者生存报告

目的基于医院登记的恶性肿瘤患者随访资料,以真实世界数据侧面反映地区恶性肿瘤的治疗效果。方法纳入2011年1月1日至2020年12月31日于广西医科大学附属肿瘤医院确诊的恶性肿瘤住院患者,共78046例包括17种恶性肿瘤的随访数据质量符合要求纳入研究。通过医院疾病管理系统及电话随访等方式收集生存随访信息,随访统计时间截至2023年6月30日。应用寿命表法估计各瘤别的1年、3年和5年总生存(overall survival,OS)率,分别对不同性别、年龄组、民族、临床分期及首次治疗时间患者的生存情况进行分析。结果收治的前5位恶性肿瘤依次为肝癌(14672例)、肺癌(10878例)、女性乳腺癌(9430例)、结直肠癌(6895例)、宫颈癌(6250例)。17种恶性肿瘤患者的1、3、5年OS率分别为76.3%、58.6%和51.4%,其中男性患者5年OS率低于女性(39.9%vs 63.1%)。各癌种OS的总体趋势均随着年龄增加而下降,其中≤44岁、45~54岁、55~64岁、65~74岁和≥75岁年龄组患者的5年OS率分别为64.0%、59.6%、52.7%、44.9%和35.7%。相比2011—2015年,2016—2020年肝癌、肺癌、女性乳腺癌、结直肠癌、鼻咽癌、淋巴瘤患者的5年OS率均明显升高(均P<0.05)。不同临床分期恶性肿瘤患者的生存状况差异有统计学意义(均P<0.01),其中Ⅰ~Ⅱ期患者的5年OS率高于Ⅲ~Ⅳ期患者(82.2%vs 43.4%)。肝癌、肺癌、女性乳腺癌、鼻咽癌、结直肠癌、宫颈癌中壮族患者的5年OS率较汉族患者明显降低(均P<0.05)。结论肝癌、肺癌是主要的收治癌种,恶性肿瘤患者中总体50%以上可以获得超过5年的生存期,不同癌种、年龄、性别、民族的恶性肿瘤患者生存状况存在明显差异,应持续实施规范、创新、多学科联合及精准的肿瘤临床治疗和早诊早治手段,以进一步改善患者的生存情况。

基于医院卫生技术评估的5种二肽基肽酶4抑制剂的临床应用情况

目的通过医院卫生技术评估(HB-HTA)对5种二肽基肽酶4抑制剂(DPP-4i)(西格列汀、维格列汀、沙格列汀、利格列汀和阿格列汀)进行评估,为医疗机构药品的遴选、临床的合理安全使用提供依据。方法通过HB-HTA,依照百分制评分体系,参考药品说明书、临床指南和文献,从安全性、有效性、经济型、创新性、适宜性和可及性等方面分别对5种DPP-4i进行评估。结果西格列汀、维格列汀、沙格列汀、利格列汀和阿格列汀得分分别为85.0、75.0、77.0、80.0、78.5分。评分差异主要在安全性、经济性、适宜性和可及性方面。西格列汀综合得分最高。结论HB-HTA评估DPP-4i结果比较合理,为医院药品遴选、安全合理使用提供依据。

4种治疗糖尿病周围神经病变补气活血类中成药的卫生技术评估

目的为临床选择糖尿病周围神经病变(DPN)治疗用补气活血类中成药提供参考。方法参考《医疗机构中成药遴选专家共识(第一版)》,结合临床实际,制订药物卫生技术评估细则,参考药品说明书、临床指南和文献,对4种中成药的安全性、有效性、经济性、适宜性、创新性、可及性、传承性进行评分,并计算总分。结果通心络胶囊、木丹颗粒、糖脉康颗粒、芪蛭降糖胶囊的评分分别为74.5分、72分、64.5分、57分。结论临床在选择治疗DPN的补气活血类中成药时,相对于糖脉康颗粒、芪蛭降糖胶囊,建议优先使用木丹颗粒、通心络胶囊。

我国公立医院医生的价值医疗服务动机探究——概念建构与量表测度

健康中国建设行动彰显了以患者为中心的价值医疗理念,对医生医疗服务行为的价值诉求也日益提高。本研究试图将一般公共组织中公共服务动机概念引入公立医院之中,提出“价值医疗服务动机”概念,作为公立医院医生的一种公共服务动机表达。本文通过质性分析和量化测度,建构出“公立医院医生价值医疗服务动机”的概念,包含责任承诺、专业坚守、声誉维护、规范遵从四个概念维度,据此形成价值医疗服务动机量表。研究发现我国公立医院医生具有多维价值特征的医疗服务动机,呈现不同动机表达或行为倾向,在实现以患者为中心的价值医疗目标实践中,不断处理与平衡其中的公共价值冲突。该量表能够为测度医生价值医疗服务动机提供有效工具,为进一步发现医生价值医疗服务动机的影响因素,提升公立医院医疗服务能力、改善医疗行为、促进医患信任等提供理论与实践支持。

体外膜肺氧合病人院际转运管理的最佳证据总结

目的:评价并总结体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)病人院际转运管理的相关证据。方法:系统检索国内外数据库及相关官网中关于ECMO病人院际转运管理的文献,根据文献评价标准进行文献质量评价并提取证据。结果:共纳入15篇文献,包括临床指南4篇,系统评价3篇,队列研究3篇,横断面研究1篇,专家共识4篇,总结出包含转运决策、转运团队建设、装备耗材管理、转运实施、转运不良事件及转运质量控制与培训6个方面的28条ECMO病人院际转运管理的最佳证据。结论:医护人员根据实际情况将证据转化为ECMO病人院际转运规范化管理方案,有利于提升转运质量,保障病人安全。

572例宫颈癌远处转移患者的转移特征及生存分析:以医院为基础的真实世界研究

背景与目的:让宫颈癌患者获得有效的治疗是全球消除宫颈癌的策略之一。本文通过分析以医院登记为基础的宫颈癌发生远处转移患者的转移特征及转移后生存情况,为改善宫颈癌患者的生存情况并最终消除宫颈癌提供真实世界的科学证据。方法:基于复旦大学附属肿瘤医院2008—2017年确诊并接受治疗的宫颈癌患者,纳入初诊时已发生远处转移或者随访过程中发生远处转移的宫颈癌患者共572例,通过患者复诊病史资料、电话随访及死因数据链接等方式收集生存信息。研究起始时间为转移发生时间,随访统计时间截至2020年11月1日。应用Kaplan-Meier法绘制总体及不同转移部位的生存曲线,并估计不同转移部位的中位生存时间及1、3和5年总生存(overall survival,OS)率。结果:随访中位时间为38.93个月,期间共发生全死因死亡348例。72.55%为单一部位转移,27.45%为多发性转移。在所有转移部位中,肺转移比例最高(41.26%),其次为骨转移(15.21%),肝转移占11.54%,位列第3位。发生转移后,1、3和5年的OS率分别为62.29%(95%CI:62.25~62.33)、33.13%(95%CI:33.08~33.18)和23.42%(95%CI:23.37~23.47)。单一部位转移中,转移至肺后的1年OS率最高(72.52%),3和5年各个部位转移后的OS差异不显著。结论:宫颈癌最易发生远处转移的部位依次为肺、骨和肝,远处转移发生后患者的生存情况较差,规范和完善远处转移后的诊疗体系,可望改善患者的生存情况。

基于循证决策的公立医院精益运营管理模式构建

全面提升公立医院高质量发展新效能是“十四五”时期深化公立医院改革的关键顶层设计。针对近年来药品耗材加成取消、支付方式改革的深度推进等公立医院面临的宏观环境变化,公立医院运营微观层面存在的诊疗业务与经济运行活动相分离、决策方式粗放、资源配置不合理以及流程亟待优化等突出问题,借鉴价值管理、精益管理和循证决策等理论,探索构建基于“业财融合、精益运营、循证决策”的三位一体公立医院精益运营管理模式。旨在打破临床诊疗业务与经济运营管理“双线”相对平行运作壁垒,探索形成业财融合直线参谋型管理新架构,充分发挥专家治院作用,将“技术型+管理型”双轮驱动的专业委员会制度纳入医院决策体系,为医院领导层科学决策提供循证支持。

以大型单中心医院登记为基础的6737例接受手术切除的胃癌患者的生存报告

背景与目的:收集以医院登记为基础的6737例接受手术切除的胃癌患者的随访资料,分析其1、3和5年观察总生存(overall survival,OS)率和无病生存(disease-free survival,DFS)率,为中国的胃癌防控和政策制定提供真实世界研究证据。方法:纳入2015年1月1日—2020年12月31日在复旦大学附属肿瘤医院接受手术治疗的胃癌患者共6737例,通过查阅患者病史了解患者的临床信息,并通过复诊病史、电话随访和死因数据链接等方式收集患者的生存随访资料,随访统计时间截至2023年11月30日。采用Kaplan-Meier法估计患者1、3和5年OS率和DFS率,并在不同年龄组、性别、治疗时期、肿瘤分期及病理学特征等亚组中分别描述。结果:接受手术切除的胃癌患者经中位50.99个月随访后,5年OS率和Ⅰ~Ⅲ期患者5年DFS率分别为70.37%和69.46%。Ⅰ期、Ⅱ期、Ⅲ期和Ⅳ期胃癌患者的5年OS率分别为94.32%、82.56%、51.01%和23.97%。不同年龄、部位、大体分型、Borrmann分型和Lauren分型的患者生存有显著差异。结论:肿瘤分期是影响胃癌患者生存的重要因素,应加强人群(尤其是高危人群)胃癌的筛查和早诊早治,进一步改善患者的生存。

价值医疗在我国临床中的应用及存在问题研究

价值医疗是一种新兴的医疗服务模式,包含健康成果和医疗成本两个方面,目的在于以相对最低的成本提供相对最优的医疗服务,为患者创造更多的价值,优化医疗资源配置。但它在我国医院的推行与发展也面临许多问题和挑战,包括患者医学信息伦理问题、患者就医体验降低问题、加重医务工作者负担以及各学科间协调性不足与跨区域优质医疗资源输出能力不足等。我国价值医疗发展应注意以患者为中心实现资源统筹,加强患者信息保护,实现以价值为导向的绩效考核促进医务工作者改革积极性。

价值医疗理念下公立医院运营管理路径选择与体系构建

价值医疗理念下,公立医院要转变运营管理的思维、目标、模式和范围,积极探索以价值医疗为导向的运营管理路径和体系,包括以患者诉求为驱动的病种管理体系,以成本控制为核心的成本管理体系,全面预算管理体系,绩效考核体系,“互联网+”医疗、人工智能和大数据分析平台,以及运营管理评价体系,在保证医疗质量、效果和效率的前提下,降低医疗成本,提升患者满意度,实现价值医疗。

基于高质量发展的公立医院人才培养策略研究

近年公立医院如何结合医院发展战略及实际情况制定医学人才培养策略,已成为影响医院高质量发展的核心要素,而首都医科大学附属北京安贞医院原有的人事管理制度在人才培养方面体现不够明确,人力资源评价、薪酬管理体系及信息化平台管理方面有待提升。我们相继出台了一系列政策,各部门形成合力,联动推进院内人才培养项目的设立与开展,通过优化整合奖项申报、资金及平台支持、绩效激励等资源,强化人才培养体系建设,完善分层培养模式建设、构建医学人才评价管理制度、提出个性化培养策略;推进基于资源消耗的相对价值比率法人才绩效薪酬改革,针对医护技人才分类评价;加强信息化人才培养平台建设,构建人才数据库,加强医院人力资源线上管理能力。一系列措施的实施使得医院优势学科和综合实力稳步提升。

基于HB-HTA的医疗新技术准入评估体系研究

医疗新技术准入评估是医疗技术纳入临床应用前的重要一环,对保证医疗服务质量和医疗安全具有关键性作用。但在准入评估具体实践过程中,还存在着准入理论框架不完善、评估指标体系不健全等问题。以卫生政策及法律法规为战略支撑,借鉴医院卫生技术评估(Hospital-based Health Technology Assessment,HB-HTA)的理论和方法,综合考虑评估主体、评估客体、评估内容等核心要素,从技术特性、安全性、有效性、经济性、适用性等维度进行指标体系设计,构建引进型医疗新技术准入评估框架,以期为医疗机构医疗技术准入管理提供理论框架和循证基础。

住院老年病人生活干预方案预防谵妄效果的Meta分析

目的:综合评价住院老年病人生活干预方案(HELP)预防谵妄的效果。方法:检索中国知网、万方数据库、MedLine等中英文数据库中关于住院老年病人生活干预方案预防谵妄的试验性研究,包括随机对照试验和非随机对照试验研究,检索时限为建库起至2022年8月15日。由2名研究者独立进行文献筛选、资料提取及质量评价后,采用RevMan 5.3软件进行Meta分析。结果:共纳入12篇文献,总体质量中等。Meta分析结果显示,住院老年病人生活干预方案可降低谵妄发生率[OR=0.40,95%CI(0.32,0.50),P<0.000 01],减轻认知功能损害[OR=0.18,95%CI(0.08,0.40),P<0.000 1],降低老年病人自理能力为重度依赖的比例[OR=0.47,95%CI(0.28,0.79),P=0.005],缩短总住院时间[MD=-3.35,95%CI(-4.09,-3.01),P<0.000 01]。结论:现有证据表明,住院老年病人生活干预方案可降低老年谵妄的发生率,减轻认知功能损害,提高老年人自理能力,缩短病人总住院时间,但由于文献质量的限制,研究结果的真实性有待更多高质量研究进一步证实。

三级公立医院绩效考核管理中KPI的应用进展

随着薪酬制度和绩效考核改革在全国深入开展,在现有体系的基础上完善绩效考核指标有助于保证考核的公平性和合理性。关键绩效指标(keyperformanceindicator,KPI)可以将医院总发展目标层层分解细化成具体的、可实现的阶段性目标,并与个人发展和薪酬相挂钩,从而调动医务人员的积极性,对于提高工作效率和实现整体战略目标具有重要价值意义。如何编制以目标为导向的KPI绩效考核体系已成为近年来研究的热点话题。基于此,笔者以政策制度改革为背景,总结传统绩效考核体系中有待改进的问题,指出考核指标改革的现实意义和重要性;综述现阶段KPI的应用领域及优势,对现存问题进行梳理,为今后医院绩效考核指标体系的构建提供借鉴。