品质改善成本效益--TQIP对外科预防性抗生素使用之影响( 65页)ppt课件

1、品質改善本钱效益TQIP對外科預防性抗生素运用之影響國泰綜合醫院 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品質本钱預防性本钱：教育訓練, 資格認定, 指標建立, 治療共識評鑑本钱：定期監測, 稽核,滿意度調查內部失敗本钱： 執行前或執行中失敗之本钱外部失敗本钱：錯誤導致醫療糾紛與賠償Effectiveness-Outcome measurement病人方面：Audit of patient outcomes(併發症,死亡率,住院日,病假日,回復任务才干,生活品質,長期結果,再發率,存活率)第三付費者：健保支出TQIP對外科預防性抗生素运用之影響抗生素費用是全院藥品費用支出之大宗合理运用抗生

6、素可防止藥物副作用89年衛生署提出本院清淨手術抗生素之运用量偏高院內缺乏系統性搜集外科預防性抗生素运用指標設定目標合理化外科預防性抗生素之运用不影響外科病患感染率為前提下掌握运用時效降低抗生素运用量方 法立意取樣：TQIP II b ：CABG、THR、TKH、ATH、APP. 五種術式收案對象之預防性抗生素运用對象：醫療服務提供者方法：Cost / Effect iveness ratio本钱效益指標运用量 运用費用运用時間過程院內感染率結果平均住院天數結果Independent t-test分科檢討改善修正任务流程，例:術前預防性抗生素改至手術室施打 (心臟外科優先，再推廣至他科)醫師準時

7、上刀(配合醫品圈) ，訂出賞罰規則以婦產科為例參考文獻，依據數據，全力溝通原有CQI團隊共識主治醫師會議修正臨床路徑資訊公開適時回饋醫品會議檢視每季趨勢比較世界、台灣、同等級醫院檢討異常值，相關科部提出說明科主任會議:公開資訊、共同協商改進提供科部相關指標書面資料全院業務會議:加強共識运用量的降低TKR、THR、CABG、APP、ATH各術式抗生素运用量與費用曲線圖各術式抗生素运用量年度比較各術式抗生素費用年度比較 t-test 得到的p-value改善情況TKR抗生素之运用季別参与TQIP运用支數金額TKR抗生素运用量同期比較季別支 數/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抗生素运用量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抗生素之运用季別参与TQIP运用支數金額THR抗生素运用量同期比較季別支 數/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抗生素运用量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抗生素之运用季別参与TQIP运用支數金額CABG抗生素运用量同期比較季別支 數/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抗生素运用量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抗生素之运用季別参与TQIP运用支數金額APP抗生素运用量同期比

12、較季別支 數/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抗生素运用量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抗生素之运用季別参与TQIP运用支數金額ATH抗生素运用量同期比較季別支 數/人次ATH抗生素費用同期比較季別元/人次改善效果运用時間掌握运用時效劃刀前30分鐘內之預防性抗生素运用情況劃刀前2小時之預防性抗生素运用情況运用期限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感染率各種院內感染率各術式相關院內感染率TKR THRCABGAPPATH改善效果每季全院院內感染率季別改善效果每季各手術式感染率(BSI、SSI、UTI、LRI)季別百分比改善效果平均住院天數天數院內感染率確無顯著差異效果运用時效改進排序：ATH、TKR、THR、CABG、APP.运用量減少情況： Cost= Cost1-Cost2 APP. (-2500) ATH (-800) CABG (-10000) TKR (-3500) THR (-6800) 結果本钱效益分析CostTQIP年