CHS-DRG付费下超支病例分析及对策

按疾病诊断相关分组(diagnosis related groups,DRG)付费是国际公认较为先进和科学的支付方式之一。实践证明,DRG的引入能够增强医疗服务的可比性,提高医疗服务效率、降低医疗服务成本[1~4]。近年来,国家医保局加快推进医保支付方式改革。北京市作为国家医疗保障疾病诊断相关分组(China health-care security DRG,CHS-DRG)国家试点城市于2022年3月15日启动66家试点医院的实际付费。

CHS-DRG和耗材集采下关节置换病组费用结构变化研究

目的:研究CHS-DRG付费联合人工关节集采改革措施实施前后关节置换病组(IC29)住院患者费用结构变化情况及影响因素,揭示改革给医院运营带来的影响。方法:分析北京某三级医院改革实施前后IC29病组住院患者的信息以及住院费用变化情况;运用结构变动度分析法,分析病组费用变化的主要类别和方向。结果:改革前后IC29病组次均住院费的结构变动度为39.4%,其中耗材费、手术费是影响住院费用变动的主要项目,累计贡献率为80.15%。改革后月均住院患者人次增加,次均住院费与耗材费下降,手术费占比升高,DRG医保盈余升高。结论:改革措施推进了CHS-DRG落地实施,使IC29病组住院费用结构趋于合理化,增加了医院可支配收入,降低了患者就医负担。但体现医务人员劳动技术价值的手术治疗费增幅有限,改革面临可能出现的诸多负性问题,需要进一步研究制定配套政策。

CHS-DRG付费改革对医院医疗质量和运行效率影响的实证分析

[目的]分析北京市某三甲医院在CHS-DRG实际付费改革前、后的医院医疗质量和运行效率的变化情况,评价改革实施效果。[方法]通过Donabedian模型建立指标集,收集其中8个指标2021年4月-2023年3月的住院数据进行中断时间序列分析。[结果]CHS-DRG付费改革后,CMI值在改革时短暂下降了0.04,但后续呈上升趋势(P<0.05),显示在长期受到了政策正向的积极影响;平均住院日在观测期内水平下降0.183天,但改革后趋势显著上升(P<0.05);住院例均费用在改革时显著下降,降低了493.45元,但改革后趋势变为上升;费用消耗指数在改革后变为上升趋势(P<0.05)。[结论]CHS-DRG支付改革推动了技术难度的提升、平均住院日和患者医疗经济负担的即时下降,但改革后长期的时间消耗和费用消耗未得到显著优化。

青蒿查尔酮合成酶(AaCHS)基因家族鉴定及光调控分析

[目的]为了解青蒿(Artemisia annua L.)查尔酮合成酶(chalcone synthase,CHS)基因家族的分子进化特性及其在不同组织部位的表达情况。[方法]从Pfam数据库下载CHS蛋白HMM模型,并使用HUMMER 3.0、Blastp和CD-search鉴定出青蒿基因组中的CHS基因家族成员。采用TBtools、EXPASy、CELLO v.2.5、MEGA 7.0、MEME、SOPMA、SWISSMODEL和PlantCARE等软件对其氨基酸与碱基序列进行生物信息学分析,通过8个不同组织部位的转录组数据对AaCHS基因家族成员进行表达分析。[结果]青蒿基因组中共有16个AaCHS基因家族成员,蛋白结构分析显示AaCHS蛋白质结构并不稳定,将其分为4个组,基因结构分析显示所有AaCHS基因蛋白均具有外显子,数量为2~4,内含子数量为0~2,其中8个AaCHS基因不具有内含子。启动子顺式作用元件分析表明该基因家族成员启动子上含有大量光响应、植物激素响应元件;CD-search验证结果发现每个AaCHS蛋白均有Chal-sti-synt_N结构域。[结论]AaCHS家族成员表达分析结果表明,16个AaCHS基因在不同组织和光处理下表达不同。GO富集结果得到GO二级分类的生物过程和分子功能,生物过程共富集了80条序列;细胞组分共富集了19条序列,其中二级分类过程细胞质中富集了11条序列,数量最多,与亚细胞定位预测结果一致;推测AaCHS基因在细胞质中调控黄酮类化合物的累积。通过青蒿光调控差异表达分析,推测AaCHS7、AaCHS10在青蒿受到红光光处理中起正向调控作用。

多花黄精查尔酮合酶PcCHS的原核表达、亚细胞定位及表达分析

【目的】探究查尔酮合酶(chalcone synthase,PcCHS)基因在多花黄精类黄酮合成中的作用,为后续解析PcCHS功能以及多花黄精新品种选育提供可靠的理论依据。【方法】以多花黄精为cDNA模板,克隆多花黄精PcCHS基因的编码序列,对该基因进行生物信息学分析。通过构建PcCHS的原核表达载体,纯化目的重组蛋白,验证该酶的体外表达活性。利用瞬时超表达体系探究该基因过表达后总黄酮的含量变化。利用Gateway技术构建亚细胞定位载体35S::PcCHS-GFP,通过本氏烟草表达系统确定目的蛋白亚细胞定位情况。【结果】PcCHS基因的开放阅读框为1 251 bp,理论分子量为44.63 kD,等电点为5.89,属于亲水蛋白,与石刁柏(Asparagus officinalis)CHS亲缘关系较近。原核表达实验表明,pET28a-PcCHS经IPTG(异丙基-β-D-硫代半乳糖苷)诱导表达可溶性重组蛋白,Western-blot显示大小约为45 kD,与预期大小一致,且纯化的目的蛋白具有一定的酶活性,能催化对香豆酰辅酶A和丙二酰辅酶A转化为柚皮素查尔酮。此外,PcCHS瞬时超表达中,PcCHS组的表达量显著高于空载K组,总黄酮含量也显著高于空载K组,最高可达1.83倍。亚细胞定位结果显示,该基因在细胞膜和细胞核中发挥作用。【结论】PcCHS基因原核表达的酶具有体外酶活性,其亚细胞定位于细胞膜和细胞核,且瞬时超表达能够显著提高多花黄精叶片总黄酮含量。

Spark Plasma Sintering of Mg-based Alloys:Microstructure,Mechanical Properties,Corrosion Behavior,and Tribological Performance

Within the past ten years,spark plasma sintering(SPS)has become an increasingly popular process for Mg manufacturing.In the SPS process,interparticle diffusion of compressed particles is rapidly achieved due to the concept of Joule heating.Compared to traditional and additive manufacturing(AM)techniques,SPS gives unique control of the structural and microstructural features of Mg components.By doing so,their mechanical,tribological,and corrosion properties can be tailored.Although great advancements in this field have been made,these pieces of knowledge are scattered and have not been contextualized into a single work.The motivation of this work is to address this scientific gap and to provide a groundwork for understanding the basics of SPS manufacturing for Mg.To do so,the existing body of SPS Mg literature was first surveyed,with a focus on their structural formation and degradation mechanisms.It was found that successful Mg SPS fabrication highly depended on the processing temperature,particle size,and particle crystallinity.The addition of metal and ceramic composites also affected their microstructural features due to the Zener pinning effect.In degradative environments,their performance depends on their structural features and whether they have secondary phased composites.In industrial applications,SPS'd Mg was found to have great potential in biomedical,hydrogen storage,battery,automotive,and recycling sectors.The prospects to advance the field include using Mg as a doping agent for crystallite size refinement and using bulk metallic Mg-based glass powders for amorphous SPS components.Despite these findings,the interactions of multi-composites on the processing-structure-property relationships of SPS Mg is not well understood.In total,this work will provide a useful direction in the SPS field and serve as a milestone for future Mg-based SPS manufacturing.

一份新的玉米永久性失绿突变体chs10的鉴定及基因克隆

【目的】利用60Co-γ射线处理自交系齐319获得了一份新的玉米叶色突变体,对该突变体进行遗传分析、基因定位与克隆,并对候选基因的功能进行初步分析。【方法】以该突变体为亲本,构建遗传分析群体和基因定位群体;通过图位克隆技术获得关键候选基因;利用生物信息学方法分析关键候选基因的结构和进化关系;通过qRT-PCR技术检测候选基因在不同组织中的表达差异;同时运用烟草瞬时表达技术对候选基因进行亚细胞定位表达分析。【结果】鉴定了一份玉米永久性失绿突变体chs10(Permanent chlorosis 10),chs10自V2时期开始,叶片从幼苗基部到顶部逐渐由绿转黄,后期的生长发育过程中不再复绿,并且,整个植株包括叶鞘、叶环、茎秆、苞叶和雄穗也均为黄色。该突变体受一对隐性核基因控制,可稳定遗传,植株生长发育正常,可正常授粉结实。突变基因被定位于玉米第10染色体长臂标记SNP-2和SNP-3之间约0.17 Mb范围内,确定了关键候选基因Zm00001d025860,qRT-PCR结果显示Zm00001d025860在玉米根、茎、叶和叶鞘中均有表达,但在叶片中高表达,亚细胞定位结果显示目标蛋白被定位在细胞膜和叶绿体中。利用STRING预测发现Zm00001d025860与卟啉结合蛋白GUN4基因互作,GUN4与叶绿素合成中的镁离子螯合酶(MgCh)具有反馈调节作用。【结论】Zm00001d025860基因的突变导致突变体chs10叶色的改变,并且Zm00001d025860可能通过参与叶绿素合成途径来调控叶色变化。突变体chs10的发现一方面丰富了玉米叶色突变体研究的基因资源,同时为解析镁离子螯合酶在叶绿素合成途径中的作用机理奠定了材料基础。

Phase-Field Simulation of Sintering Process:A Review

Sintering,a well-established technique in powder metallurgy,plays a critical role in the processing of high melting point materials.A comprehensive understanding of structural changes during the sintering process is essential for effective product assessment.The phase-field method stands out for its unique ability to simulate these structural transformations.Despite its widespread application,there is a notable absence of literature reviews focused on its usage in sintering simulations.Therefore,this paper addresses this gap by reviewing the latest advancements in phase-field sintering models,covering approaches based on energy,grand potential,and entropy increase.The characteristics of various models are extensively discussed,with a specific emphasis on energy-based models incorporating considerations such as interface energy anisotropy,tensor-form diffusion mechanisms,and various forms of rigid particle motion during sintering.Furthermore,the paper offers a concise summary of phase-field sintering models that integrate with other physical fields,including stress/strain fields,viscous flow,temperature field,and external electric fields.In conclusion,the paper provides a succinct overview of the entire content and delineates potential avenues for future research.

Effect of sintering temperature and holding time on structure and properties of Li_(1.5)Ga_(0.5)Ti_(1.5)(PO_4)_(3)electrolyte with fast ionic conductivity

Li_(1.5)Ga_(0.5)Ti_(1.5)PO_(4))_(3)(LGTP)is recognized as a promising solid electrolyte material for lithium ions.In this work,LGTP solid electrolyte materials were prepared under different process conditions to explore the effects of sintering temperature and holding time on relative density,phase composition,microstructure,bulk conductivity,and total conductivity.In the impedance test under frequency of 1-10^(6) Hz,the bulk conductivity of the samples increased with increasing sintering temperature,and the total conductivity first increased and then decreased.SEM results showed that the average grain size in the ceramics was controlled by the sintering temperature,which increased from(0.54±0.01)μm to(1.21±0.01)μm when the temperature changed from 750 to 950°C.The relative density of the ceramics increased and then decreased with increasing temperature as the porosity increased.The holding time had little effect on the grain size growth or sample density,but an extended holding time resulted in crack generation that served to reduce the conductivity of the solid electrolyte.

Spark Plasma Sintering of Boron Carbide Using Ti_(3)SiC_(2) as a Sintering Additive

Boron carbide has unique properties for wide application possibilities;however,poor sinterability limits its applications.One approach to overcome this limitation is the addition of secondary phases into boron carbide.Boron carbide based composite ceramics are produced by the direct addition of secondary phases into the structure or via reactive sintering using a sintering additive.The present study investigated the effect of Ti_(3)SiC_(2) addition to boron carbide by reactive spark plasma sintering in the range of 1700-1900℃.Ti_(3)SiC_(2) phase decomposed at high temperatures and reacted with B4C to form secondary phases of TiB2 and SiC.The results demonstrated that the increase of Ti_(3)SiC_(2) addition(up to 15 vol%)effectively promoted the densification of B4C and yielded higher hardness.However,as the amount of Ti_(3)SiC_(2) increased further,the formation of microstructural inhomogeneity and agglomeration of secondary phases caused a decrease in hardness.

Boosting thermoelectric efficiency of Ag_(2)Se through cold sintering process with Ag nano-precipitate formation

Silver selenide(Ag_(2)Se)stands out as a promising thermoelectric(TE)material,particularly for applications near room temper-atures.This research presents a novel approach for the fabrication of bulk Ag_(2)Se samples at a relatively low temperature(170℃)using the cold sintering process(CSP)with AgNO_(3)solution as a transient liquid agent.The effect of AgNO_(3)addition during CSP on the micro-structure and TE properties was investigated.The results from phase,composition and microstructure analyses showed that the introduc-tion of AgNO_(3)solution induced the formation of Ag nano-precipitates within the Ag_(2)Se matrix.Although the nano-precipitates do not af-fect the phase and crystal structure of orthorhombicβ-Ag_(2)Se,they suppressed crystal growth,leading to reduced crystallite sizes.The samples containing Ag nano-precipitates also exhibited high porosity and low bulk density.Consequently,these effects contributed to sig-nificantly enhanced electrical conductivity and a slight decrease in the Seebeck coefficient when small Ag concentrations were incorpor-ated.This resulted in an improved average power factor from~1540μW·m^(−1)·K^(−2)for pure Ag_(2)Se to~1670μW·m^(−1)·K^(−2)for Ag_(2)Se with additional Ag precipitates.However,excessive Ag addition had a detrimental effect on the power factor.Furthermore,thermal conductiv-ity was effectively suppressed in Ag_(2)Se fabricated using AgNO_(3)-assisted CSP,attributed to enhanced phonon scattering at crystal inter-faces,pores,and Ag nano-precipitates.The highest figure-of-merit(zT)of 0.92 at 300 K was achieved for the Ag_(2)Se with 0.5wt%Ag dur-ing CSP fabrication,equivalent to>20%improvement compared to the controlled Ag_(2)Se without extra Ag solution.Thus,the process outlined in this study presents an effective strategy to tailor the microstructure of bulk Ag_(2)Se and enhance its TE performance at room temperature.

Effect of Sintering Temperature on the Microstructure and Mechanical Properties of Nanocrystalline Cemented Carbide

WC-Co nanocrystalline nitrogen-containing cemented carbides were prepared by vacuum sintering and low pressure sintering.The sintering processes of Cr_(2)(C,N)doped nano WC-Co powders were studied by using thermogravimetric analysis(TGA)and differential scanning calorimetry(DSC).The effect of sintering temperature on the microstructure and mechanical properties of nanocrystalline cemented carbide was studied by scanning electron microscope(SEM),high resolution transmission electron microscope(HRTEM)and mechanical property test.The results showed that the nano WC grains began to grow in the solid phase sintering stage.A high-performance nano-nitrogen-containing cemented carbide with uniform microstructure and good interfacial bonding can be obtained by increasing the sintering temperature to 1380℃.It has a transverse rupture strength(TRS)of 5057 MPa and a hardness of 1956 HV30.

Duplicated chalcone synthase(CHS)genes modulate flavonoid production in tea plants in response to light stress

In tea plants,the abundant flavonoid compounds are responsible for the health benefits for the human body and define the astringent flavor profile.While the downstream mechanisms of flavonoid biosynthesis have been extensively studied,the role of chalcone synthase(CHS)in this secondary metabolic process in tea plants remains less clear.In this study,we compared the evolutionary profile of the flavonoid metabolism pathway and discovered that gene duplication of CHS occurred in tea plants.We identified three CsCHS genes,along with a CsCHS-like gene,as potential candidates for further functional investigation.Unlike the CsCHS-like gene,the CsCHS genes effectively restored flavonoid production in Arabidopsis chs-mutants.Additionally,CsCHS transgenic tobacco plants exhibited higher flavonoid compound accumulation compared to their wild-type counterparts.Most notably,our examination of promoter and gene expression levels for the selected CHS genes revealed distinct responses to UV-B stress in tea plants.Our findings suggest that environmental factors such as UV-B exposure could have been the key drivers behind the gene duplication events in CHS.

Fabrication of YAG:Ce^(3+) and YAG:Ce^(3+),Sc^(3+) Phosphors by Spark Plasma Sintering Technique

In this study,a single-doped phosphors yttrium aluminum garnet(Y_(3)Al_(5)O_(12),YAG):Ce^(3+),single-doped YAG:Sc^(3+),and double-doped phosphors YAG:Ce^(3+),Sc^(3+) were prepared by spark plasma sintering(SPS)(lower than 1 200℃).The characteristics of synthesized phosphors were determined using scanning electron microscopy(SEM),X-ray diffraction(XRD),and fluorescence spectroscopy.During SPS,the lattice structure of YAG was maintained by the added Ce^(3+) and Sc^(3+).The emission wavelength of YAG:Ce^(3+) prepared from SPS(425-700 nm) was wider compared to that of YAG:Ce^(3+) prepared from high-temperature solid-state reaction(HSSR)(500-700 nm).The incorporation of low-dose Sc^(3+) in YAG:Ce^(3+) moved the emission peak towards the short wavelength.

Spark plasma sintering of tungsten-based WTaVCr refractory high entropy alloys for nuclear fusion applications

W-based WTaVCr refractory high entropy alloys (RHEA) may be novel and promising candidate materials for plasma facing components in the first wall and diverter in fusion reactors. This alloy has been developed by a powder metallurgy process combining mechanical alloying and spark plasma sintering (SPS). The SPSed samples contained two phases, in which the matrix is RHEA with a body-centered cubic structure, while the oxide phase was most likely Ta2VO6through a combined analysis of X-ray diffraction (XRD),energy-dispersive spectroscopy (EDS), and selected area electron diffraction (SAED). The higher oxygen affinity of Ta and V may explain the preferential formation of their oxide phases based on thermodynamic calculations. Electron backscatter diffraction (EBSD) revealed an average grain size of 6.2μm. WTaVCr RHEA showed a peak compressive strength of 2997 MPa at room temperature and much higher micro-and nano-hardness than W and other W-based RHEAs in the literature. Their high Rockwell hardness can be retained to at least 1000°C.

Atomistic investigation of pressure effects on sintering of bimetallic core-shell nanoparticles

Pressure-assisted sintering(PAS)utilizing bimetallic core-shell nanoparticles(CS NPs)has garnered widespread attention for its ability to produce advanced components with excellent thermal and elec-trical conductivities,even at low temperatures.This study presents the first investigation into the PAS of bimetallic CS NPs,using Ag-coated Cu material as a representative system,through all-atom molecu-lar dynamics(MD)simulations.The study provides detailed insights into the atomic-scale processes and mechanisms that govern pressure-assisted sintering,elucidating the coalescence phenomena and reveal-ing the significant influence of external pressure.By comparing atomistic behaviors,such as diffusion,migration,and microstructure evolution,between PAS and thermal sintering,a deeper understanding of the underlying mechanisms is achieved.Furthermore,the results highlight the importance of considering microstructural characteristics in addition to void fraction assessment for accurately estimating mechani-cal properties.This study enhances our understanding of sintering methods and offers a new perspective on designing process conditions in the PAS process.

Effects of Diamond on the Mechanical Properties and Thermal Conductivity of Si_(3)N_(4)Composites Fabricated Using Spark Plasma Sintering

Micrometer-sized diamonds were incorporated into silicon nitride(Si_(3)N_(4))matrix to manufacture high-performance Si_(3)N_(4)-based composites using spark plasma sintering at 1500℃under 50 MPa.The effects of the diamond content on the phase composition,microstructure,mechanical properties and thermal conductivity of the composites were investigated.The results showed that the addition of diamond could effectively improve the hardness of the material.The thermal conductivity of Si_(3)N_(4)increased to 52.97 W/m·k at the maximum with the addition of 15 wt%diamond,which was 27.5%higher than that of the monolithic Si_(3)N_(4).At this point,the fracture toughness was 7.54 MPa·m^(1/2).Due to the addition of diamond,the composite material generated a new substance,MgSiN2,which effectively combined Si_(3)N_(4)with diamond.MgSiN2 might improve the hardness and thermal conductivity of the materials.

Computational Analysis of Selective Laser Sintering of Inconel 625

A two-dimensional multi-physics finite element model is developed to simulate the Selective Laser Sintering(SLS)process using Inconel 625 powders.The validity of the developed model is first assessed by comparing its results with experimental data.Various factors such as phase transition,recoil pressure,surface tension,and theMarangoni force are considered.The study’s findings underscore that the morphology and thermal-fluid dynamics of the molten pool in the SLS process are predominantly shaped by the influence of the Marangoni force and recoil pressure acting on its surface.The recoil pressure at the front of the laser spot rises exponentially with temperature,making the liquid metal move downward,and creating a depression at the pool’s head.It also causes particles to splash from the pool’s rear edge.The study explores the influence of the backward Marangoni force,where hightemperature liquid flows from the front to the rear of the molten pool,creating a vortex and moving the pool in the rear.Process parameters like laser intensity,scan speed,and spot size were analyzed.The findings indicate that higher laser power lower scanning speed and laser beam spot size lead to increased width and depth of the molten pool.

Feasibility Analysis of the Sintering Flue Gas Oxidation Method for Denitrification Technology Route

With the vigorous development of China’s iron and steel industry and the introduction of ultra-low emission policies, the emission of pollutants such as SO2 and NOx has received unprecedented attention. At present, the commonly used denitrification methods include selective catalytic reduction (SCR), active coke, etc. As a newly developed denitrification technology, oxidation denitrification is not widely used, and the technical level is mixed, and there might be problems such as yellow smoke, secondary pollution and ozone escape in the practical application. In this paper, problems existing in the denitrification process of sintering flue gas oxidation are analyzed, and a 320 m2 sintering machine is taken as an example. Comparing the denitrification technology of sintering industry, it could be seen that the denitrification technology route of oxidation method has low pollution, low cost and high comprehensive environmental benefits, and has greatly potential development.

基于机器学习的医院CHS-DRG分组费用分析——以“胆囊切除手术不伴并发症和合并症”组为例

目的:采用机器学习技术建立院内“胆囊切除手术不伴并发症和合并症”分组的费用权重模型,进而分析该分组中的合理费用组成方式,找到实际管控和降低住院费用的方法。方法:以重庆市2021年发布的DRG管理方案为基础,收集2021年1月至2024年4月HC35分组的病案数据,按照住院总费用与分组补偿标准比值将其分为全部数据组、30%~100%正常补偿组和90%~100%标准补偿组,然后以物价模块分类为基础建立各类的费用集合,再采用梯度下降技术分析各物价模块在费用中的权重并以此建立分析模型,接着使用统计假设检验分别验证运算数据,经过分析后得到最终采用的权重模型。确认模型后,以重庆市2024年发布的DRG管理方案对前期数据进行重新分组计算,得到新的分组结果并追加收集2024年4月以后HC25分组的病案数据,经过模型拟合得到最新的费用权重及占比。结果:采用的数据模型为90%~100%标准补偿组模型,排列靠前的模块权重分别为(耗材费1.343[28.09%]、治疗费1.170[24.47%]、西药费0.846[17.70%]、检验检查费0.765[16.00%]、医疗服务费0.459[9.69%])。之后对各项内涵展开针对性讨论,探讨合理的费用控制方法。结论:将信息化技术结合临床路径等控制方式建立DRG分组的费用管理模型,是践行理论结合实际的良性操作行为,在未来的医疗机构费用管理中可以得到广泛的推广。