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研究生:李騰裕
研究生(外文):Teng-Yu Lee
論文名稱:實施最新的臨床路徑對非靜脈瘤型急性上消化道出血治療的成本效益探討
論文名稱(外文):Cost Effectiveness of an Updated Clinical Pathway for Acute Nonvariceal Upper Gastrointestinal Bleeding
指導教授:陳潭陳潭引用關係
指導教授(外文):Tam Chan
學位類別:碩士
校院名稱:東海大學
系所名稱:工業工程與經營資訊學系
學門:工程學門
學類:工業工程學類
論文種類:學術論文
論文出版年:2007
畢業學年度:95
語文別:英文
論文頁數:73
中文關鍵詞:臨床路徑要徑胃腸出血
外文關鍵詞:clinical care pathwaycritical pathwaygastrointestinal hemorrhage
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非靜脈瘤型急性上消化道出血是臨床醫師所經常遭遇的一種醫療急症,而這種疾病也高度地消耗了許多的醫療資源與金錢;然而,至目前為止,仍然只有極少數的證據可以證實將臨床路徑的方法運用於非靜脈瘤型急性上消化道出血時,具有經濟有效的成效。本研究乃是以最新的實証醫學(evidence-based medicine)為基礎來設計一套處理非靜脈瘤型急性上消化道出血的臨床路徑,並導入醫師提示系統(physician reminder system),以增進醫師對於臨床路徑的遵從性,希望可以藉此研究證實運用臨床路徑的方法可以在節省成本及醫療品質的各項指標上有明顯的助益。
本研究除了設計以最新實証醫學為基礎的臨床路徑,並建立由主要的提示者(總住院醫師)、核對清單(checklist)、及案例回顧會議所建構的醫師提示系統後,將本臨床路徑導入實施於一般內科病房之中。藉由比較導入臨床路徑前後的各項花費指標:昂貴靜脈注射劑型制酸藥物的使用、住院天數、以及各項費用(包括藥費、檢查費用),來比較臨床路徑是否具有節省成本的效果。此外,藉由比較導入臨床路徑前後的各項醫療品質指標:住院期間再出血率、住院期間重複做胃鏡率、以及三十天內因出血而再住院率,來比較臨床路徑是否會影響醫療品質。
比較結果顯示,實施本臨床路徑後,明顯地減少昂貴靜脈注射型制酸藥物的使用由88%至34%、減少每位病患的平均住院天數由6.7天至3.6天、減少每位病患的平均藥費由新台幣8768元至3940元(費用節省55.1%)、減少每位病患的平均檢查費用由新台幣12560元至9493元(費用節省24.4%)、以及減少每位病患的平均總住院費用由新台幣33142元至19519元(費用節省41.1%)。此外,醫療品質的各項指標在實施本臨床路徑之後,並未有明顯的改變。
本研究的結論為:以臨床路徑的方法來處理非靜脈瘤型急性上消化道出血,具有經濟有效的優點;而透過醫師提示系統來增進醫師在臨床實務時對於臨床路徑的遵從性,可能促進了本臨床路徑的成功。
Acute nonvariceal upper gastrointestinal (UGI) bleeding is a common medical emergency encountered by primary physicians that causes high costs, but there still is little evidence to prove the cost effectiveness of a clinical care pathway. We introduce the physician reminder system into an updated clinical pathway to improve physicians' adherence and hope there is significant impact on outcomes.
The updated evidence-based clinical care pathway was designed and implemented in the general internal medicine wards, and used the physician reminder system that included chief residents as major reminders, checklists, and case review meetings. Use of medicine for acid suppression, length of stay (LOS), and variable costs including medicine, diagnostic tests were compared between patients before and after implementation of the clinical pathway. Quality of care was monitored by the rate of recurrent bleeding during hospitalization, rate of repeated UGI endoscopy, and rate of readmission due to recurrent bleeding within 30 days after discharge.
This clinical pathway significantly reduced the use of intravenous medicine for acid suppression from 88% to 34%, with mean LOS per patient down from 6.7 to 3.6 days, mean cost of medicine per patient down from NTD 8768 to NTD 3940 (cost down 55.1%), mean cost of diagnostic tests per patient down from NTD 12560 to NTD 9493 (cost down 24.4%), and mean total hospital cost per patient down from NTD 33142 to NTD 19519 (cost down 41.1%). The indicators for quality of care were not significantly different.
In conclusion, the clinical care pathway is a cost-effective method in management of acute nonvariceal UGI bleeding, and the physician reminder system may improve the compliance of primary physicians throughout clinical practice making the clinical pathway successful.
Chapter 1. Introduction 1
1.1 Background 1
1.2 Objectives 2
1.3 Skeleton of study 3
1.4 Processes of study 4
1.5 Hypothesis and limitation of study 6
1.5.1 Hypothesis 6
1.5.2 Limitation of study 6
Chapter 2. Literature review 7
2.1 Development of clinical pathways 7
2.2 Definition of clinical pathways 8
2.3 Unsettled issues relating to clinical pathways 8
2.4 Studies of clinical pathway for acute nonvariceal UGI bleeding in the world 9
2.5 Studies of clinical care pathway for acute nonvariceal UGI bleeding in Taiwan 11
2.6 The role of reminders in clinical pathways 11
2.7 Clinical manifestation and specific therapy for acute nonvariceal UGI bleeding 12
2.8 Relationship of chronic comorbidity and outcomes of hospital care 14
Chapter 3. Materials and methods 16
3.1 Development of the clinical pathway 16
3.2 Dissemination of the clinical pathway 19
3.3 Implementation of the clinical pathway 19
3.4 The physician reminder system of clinical pathway 20
3.5 The exclusion criteria and control group 20
3.6 The measured outcomes 21
3.7 The comorbidity status of patients 22
3.8 Methods of statistics 22
Chapter 4. Results 24
4.1 Data presentation 24
4.2 The demographic features, comorbidity, and severity of GI bleeding 24
4.3 The measured outcomes before and after implementation of the clinical pathway 26
4.4 Indicators for quality of care 31
Chapter 5. Discussion 32
5.1 The factors influencing outcomes of guidelines or clinical pathways 32
5.1.1 The physician reminder system 33
5.1.2 Underlying comorbidity status 35
5.2 The goals influencing the outcomes of clinical pathways 35 5.2.1 Early endoscopy 35
5.2.2 Acid suppression therapy 36
5.2.3 Lean diagnostic tests 37
5.3 Quality of care after implementation of clinical pathway 38
5.4 Conclusion and further direction 38
REFERENCE 40
APPENDIX 46
Appendix Table 1.1 Data before implementation of the clinical pathway (age, sex, LOS, time to endoscopy) 46
Appendix Table 1.2 Data before implementation of the clinical pathway (local therapy, high risk, rebleeding, readmission, repeat endoscopy, blood transfusion) 48
Appendix Table 1.3 Data before implementation of the clinical pathway (CXR, KUB, EKG, PPI, oral medicine for acid suppression only) 50
Appendix Table 1.4 Data before implementation of the clinical pathway (costs of medicine, diagnostic tests at ER) 52
Appendix Table 1.5 Data before implementation of the clinical pathway (costs of ward services, diagnostic tests, medicine at wards) 54
Appendix Table 1.6 Data before implementation of the clinical pathway (total costs of medicine and diagnostic tests, Charlson comorbidity index) 56
Appendix Table 2.1 Data after implementation of the clinical pathway (age, sex, LOS, time to endoscopy) 58
Appendix Table 2.2 Data after implementation of the clinical pathway (local therapy, high risk, rebleeding, readmission, repeat endoscopy, blood transfusion) 60
Appendix Table 2.3 Data after implementation of the clinical pathway (CXR, KUB, EKG, PPI, oral medicine for acid suppression only) 62
Appendix Table 2.4 Data after implementation of the clinical pathway (costs of medicine, diagnostic tests at ER) 64
Appendix Table 2.5 Data after implementation of the clinical pathway (costs of ward services, diagnostic tests, medicine at wards) 66
Appendix Table 2.6 Data after implementation of the clinical pathway (total costs of medicine and diagnostic tests, Charlson comorbidity index) 68
Appendix Table 3.1 Differences between quantitative variables before and after implementation of the clinical pathway 70
Appendix Table 3.2 Differences between categorical variables before and after implementation of the clinical pathway 72
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