品質(zhì)改善成本效益--TQIP對外科預(yù)防性抗生素使用之影響( 65頁)ppt課件

1、品質(zhì)改善本錢效益TQIP對外科預(yù)防性抗生素運用之影響國泰綜合醫(yī)院 黃清水副院長Model of a National Health SystemHealth ResultManagementOrganizationEconomicsupportResourcesServices deliveryHealth NeedsLimited Medical Resourcesvs.Optimal Healthcare QualityLow Cost vs High Effectiveness= Cost-effective(The relationship between achieving cert

2、ain objectives and consumption of resources， costs vs outcomes)Efficacy vs Effectiveness Efficacy is a measure of the extent to which objectives (result, cure) are achieved in real practice settings. Effectiveness concerns generalizability of results of treatment.Healthcare Cost as % of GNP13.4% - 1

3、3.7%(5.4% Taiwan)US Healthcare Cost in $1.491 TrillionPredicted increase of 10% in 2000 2.2 Trillion by 2021Cost-EffectivenessCLIENTPROVIDERPAYERSOCIETYCost of Surgical OperationsExpendable suppliesInstrumentsEquipmentImplantsFacility CostEmployeesPre-op testingExpendable suppliesLaparotomy packageG

4、own, gloves and towelsPrepEKG and oxygen finger padsAnesthesia gases and masksLocal anesthesia and antibioticsMedical (Year 2000)Hospital 40%Professional 42%Pharmacy 18%(25% Taiwan)Full Time EmployeeReceptionistPreop nurseCirculating nurseSurgical techRecovery room nurseOR supervisorCOO facility- $2

5、2/hr for 9-9/5hrs for each case $209/hr. for every case品質(zhì)本錢預(yù)防性本錢：教育訓(xùn)練, 資格認(rèn)定, 指標(biāo)建立, 治療共識評鑑本錢：定期監(jiān)測, 稽核,滿意度調(diào)查內(nèi)部失敗本錢： 執(zhí)行前或執(zhí)行中失敗之本錢外部失敗本錢：錯誤導(dǎo)致醫(yī)療糾紛與賠償Effectiveness-Outcome measurement病人方面：Audit of patient outcomes(併發(fā)癥,死亡率,住院日,病假日,回復(fù)任務(wù)才干,生活品質(zhì),長期結(jié)果,再發(fā)率,存活率)第三付費者：健保支出TQIP對外科預(yù)防性抗生素運用之影響抗生素費用是全院藥品費用支出之大宗合理運用抗生

6、素可防止藥物副作用89年衛(wèi)生署提出本院清淨(jìng)手術(shù)抗生素之運用量偏高院內(nèi)缺乏系統(tǒng)性搜集外科預(yù)防性抗生素運用指標(biāo)設(shè)定目標(biāo)合理化外科預(yù)防性抗生素之運用不影響外科病患感染率為前提下掌握運用時效降低抗生素運用量方 法立意取樣：TQIP II b ：CABG、THR、TKH、ATH、APP. 五種術(shù)式收案對象之預(yù)防性抗生素運用對象：醫(yī)療服務(wù)提供者方法：Cost / Effect iveness ratio本錢效益指標(biāo)運用量 運用費用運用時間過程院內(nèi)感染率結(jié)果平均住院天數(shù)結(jié)果Independent t-test分科檢討改善修正任務(wù)流程，例:術(shù)前預(yù)防性抗生素改至手術(shù)室施打 (心臟外科優(yōu)先，再推廣至他科)醫(yī)師準(zhǔn)時

7、上刀(配合醫(yī)品圈) ，訂出賞罰規(guī)則以婦產(chǎn)科為例參考文獻(xiàn)，依據(jù)數(shù)據(jù)，全力溝通原有CQI團(tuán)隊共識主治醫(yī)師會議修正臨床路徑資訊公開適時回饋醫(yī)品會議檢視每季趨勢比較世界、臺灣、同等級醫(yī)院檢討異常值，相關(guān)科部提出說明科主任會議:公開資訊、共同協(xié)商改進(jìn)提供科部相關(guān)指標(biāo)書面資料全院業(yè)務(wù)會議:加強(qiáng)共識運用量的降低TKR、THR、CABG、APP、ATH各術(shù)式抗生素運用量與費用曲線圖各術(shù)式抗生素運用量年度比較各術(shù)式抗生素費用年度比較 t-test 得到的p-value改善情況TKR抗生素之運用季別參與TQIP運用支數(shù)金額TKR抗生素運用量同期比較季別支 數(shù)/人次TKR抗生素費用同期比較季別元/人次89Mean+

8、SD90Mean+SD91Mean +SDp-valueQ134.27+ 13.0627.37+12.510.61Q234.81+12.5631.54+14.670.34Q324.76+11.8628.29+11.070.65Q444.15+59.6420.82+10.300.13TKR抗生素運用量89Mean+SD90Mean+SD91Mean +SDp-valueQ14738.25+1897.362731.37+1192.040.39Q23522.42+1261.183144.23+1498.980.24Q32490.36+1228.742976.41+1146.790.80Q46358.

9、30+8595.152154.23+1042.840.09TKR抗生素費用改善情況THR抗生素之運用季別參與TQIP運用支數(shù)金額THR抗生素運用量同期比較季別支 數(shù)/人次THR抗生素費用同期比較季別元/人次89Mean+SD90Mean+SD91Mean +SDp-valueQ134.27+13.0627.26+13.470.85 Q230.67+7.9927.70+15.800.30Q326.68+8.1929.82+11.810.08Q444.55+12.0732.82+35.920.10THR抗生素運用量89 Mean+SD90Mean+SD91Mean +SDp-valueQ14738

10、.25+1897.362751.70+1369.770.35Q23205.90+991.792809.52+1615.550.50Q32691.74+870.953091.06+1183.940.15Q49804.6+1808.384337.05+7752.430.08THR抗生素費用改善情況CABG抗生素之運用季別參與TQIP運用支數(shù)金額CABG抗生素運用量同期比較季別支 數(shù)/人次CABG抗生素費用同期比較季別元/人次89Mean+SD90Mean+SD91Mean +SDp-valueQ163.26+50.4245.58+14.290.11Q256.50+22.6848.83+21.510

11、.63Q350.67+20.7839.31+20.120.62Q471.77+59.8658.50+28.120.31CABG抗生素運用量899091p-valueMean+SDMean+SDMean +SDQ112402.98+16464.785318.92+2914.660.08Q28335.23+2908.485180.22+2111.060.08Q36072.93+32583964413.00+2517.470.42Q414891.34+26166.637665.00+4383.870.12CABG抗生素費用改善情況APP抗生素之運用季別參與TQIP運用支數(shù)金額APP抗生素運用量同期比

12、較季別支 數(shù)/人次APP抗生素費用同期比較季別元/人次89Mean+SD90Mean+SD91Mean +SDp-valueQ129.70+39.0621.82+13.140.00 Q224.83+16.9123.53+9.880.02 Q320.78+17.4021.78+8.830.00 Q430.04+20.0522.02+11.140.00 APP抗生素運用量p.01 p.05899091p-valueMean+SDMean+SDMean +SDQ1Q2Q3Q44630.09+4354.193972.84+7783.552578.24+2263.222106.53+3039.06225

13、5.18+1286.892177.07+1419.53 2459.81+1115.65 2199.52+1015.130.000.000.000.00APP抗生素費用p.01改善情況ATH抗生素之運用季別參與TQIP運用支數(shù)金額ATH抗生素運用量同期比較季別支 數(shù)/人次ATH抗生素費用同期比較季別元/人次改善效果運用時間掌握運用時效劃刀前30分鐘內(nèi)之預(yù)防性抗生素運用情況劃刀前2小時之預(yù)防性抗生素運用情況運用期限24小時TKR THRCABGAPPATH百分比II-b: Surgical ProphylaxisRate-Knee Arthroplasty Surgical Prophylaxis

14、 Within 30 minutes Prior to Incision (2001q1)(8/18)(8/26)(13/31)(13/20)(13/25)百分比II-b: Surgical ProphylaxisRate-Hip Arthroplasty Surgical Prophylaxis Within 30 minutes Prior to Incision (2001q1)(5/15)(3/20)(7/26)(10/30)(6/26)百分比II-b: Surgical ProphylaxisRate-CABG Surgical Prophylaxis Within 30 minut

15、es Prior to Incision (2001q1)(5/22)(12/36)(3/15)(4/25)(7/28)百分比II-b: Surgical ProphylaxisRate-Appendectomy Surgical Prophylaxis Within 30 minutes Prior to Incision (2001q1)(9/79)(5/104)(3/101)(6/70)(5/68)百分比II-b: Surgical ProphylaxisRate-Abdominal Hysterectomy Surgical Prophylaxis Within 30 minutes

16、Prior to Incision (2001q1)(33/57)(43/57)(50/68)(34/36)(34/43)百分比II-b: Surgical ProphylaxisRate-Knee Arthroplasty Surgical Prophylaxis Within 2 hours Prior to Incision(17/22)(17/18)(25/26)(27/31)(20/20)(24/25)百分比II-b: Surgical ProphylaxisRate-Hip Arthroplasty Surgical Prophylaxis Within 2 hours Prior

17、 to Incision(18/22)(12/15)(19/20)(21/26)(30/30)(22/26)百分比II-b: Surgical ProphylaxisRate-CABG Surgical Prophylaxis Within 2 hours Prior to Incision(31/33)(21/22)(35/36)(15/15)(25/25)(28/28)百分比II-b: Surgical ProphylaxisRate-Appendectomy Surgical Prophylaxis Within 2 hours Prior to Incision(80/87)(67/7

18、9)(92/104)(88/101)(61/68)(68/70)百分比II-b: Surgical ProphylaxisRate-Abdominal Hysterectomy Surgical Prophylaxis Within 2 hours Prior to Incision(50/57)(73/74)(50/57)(67/68)(35/36)(43/45)百分比II-b: Surgical ProphylaxisRate-Abdominal Hysterectomy Surgical Prophylaxis for 24 hours or less (2001q1)(17/57)(53/57)(51/58)(34/36)(40/45)改善效果感染率全院院內(nèi)感染率各種院內(nèi)感染率各術(shù)式相關(guān)院內(nèi)感染率TKR THRCABGAPPATH改善效果每季全院院內(nèi)感染率季別改善效果每季各手術(shù)式感染率(BSI、SSI、UTI、LRI)季別百分比改善效果平均住院天數(shù)天數(shù)院內(nèi)感染率確無顯著差異效果運用時效改進(jìn)排序：ATH、TKR、THR、CABG、APP.運用量減少情況： Cost= Cost1-Cost2 APP. (-2500) ATH (-800) CABG (-10000) TKR (-3500) THR (-6800) 結(jié)果本錢效益分析CostTQIP年