品質(zhì)改善成本效益—TQIP對(duì)外科預(yù)防性抗生素使用之影響國(guó)泰綜合醫(yī)院TQIP小組國(guó)泰綜合醫(yī)院黃清水副院長(zhǎng)Model

of

a

National

Health

SystemHealth

ResultManagementOrganizationEconomicsupportResourcesServices

deliveryHealth

Needs國(guó)泰綜合醫(yī)院TQIP小組Limited

Medical

Resourcesvs.國(guó)泰綜合醫(yī)院TQIP小組Optimal

Healthcare

QualityLowCostvs High

Effectiveness=

Cost-effective國(guó)泰綜合醫(yī)院TQIP小組(The

relationship

betweenachievingcertainobjectivesand

consumptionofresources，costsvs

outcomes)Efficacy

vs Effectiveness國(guó)泰綜合醫(yī)院TQIP小組Efficacyisameasureoftheextenttowhich

objectives(result,cure)areachievedinreal

practice

settings. Effectiveness

concerns

generalizability

ofresults

of

treatment.Healthcare

Cost

as % ofGNP國(guó)泰綜合醫(yī)院TQIP小組13.4% - 13.7%(5.4% Taiwan)US

Healthcare

Cost

in

$$國(guó)泰綜合醫(yī)院TQIP小組1.491 TrillionPredicted

increase

of

10%

in

2000

2.2

Trillion

by

2008Cost--EffectivenessCLIENTPROVIDERPAYERSOCIETY國(guó)泰綜合醫(yī)院TQIP小組Costof Surgical

Operations國(guó)泰綜合醫(yī)院TQIP小組Expendable

suppliesInstrumentsEquipmentImplantsFacility

CostEmployeesPre-op

testingExpendable

supplies國(guó)泰綜合醫(yī)院TQIP小組Laparotomy

packageGown,

gloves

and

towelsPrepEKG

and

oxygen

finger

padsAnesthesia

gases

and

masksLocal

anesthesia

and

antibioticsMedical

(Year 2000)國(guó)泰綜合醫(yī)院TQIP小組Hospital 40%Professional 42%Pharmacy 18%(25%

Taiwan)Full

Time

Employee國(guó)泰綜合醫(yī)院TQIP小組ReceptionistPreop

nurseCirculating

nurseSurgical

techRecovery

room

nurseOR

supervisorCOOfacility-$22/hrfor9-9/5hrsfor

each

case$209/hr.

for

every

case品質(zhì)成本國(guó)泰綜合醫(yī)院TQIP小組預(yù)防性成本：教育訓(xùn)練,

資格認(rèn)定,

指標(biāo)建立,

治療共識(shí)評(píng)鑑成本：定期監(jiān)測(cè),

稽核,滿意度調(diào)查內(nèi)部失敗成本：執(zhí)行前或執(zhí)行中失敗之成本外部失敗成本：錯(cuò)誤導(dǎo)致醫(yī)療糾紛與賠償Effectiveness-Outcomemeasurement國(guó)泰綜合醫(yī)院TQIP小組病人方面：Auditofpatientoutcomes(

併發(fā)癥,死亡率,住院日,病假日,回復(fù)工作能力,生活品質(zhì),長(zhǎng)期結(jié)果,再發(fā)率,存活率)第三付費(fèi)者：健保支出TQIP對(duì)外科預(yù)防性抗生素使用之影響國(guó)泰綜合醫(yī)院TQIP小組抗生素費(fèi)用是全院藥品費(fèi)用支出之大宗合理使用抗生素可避免藥物副作用89年衛(wèi)生署提出本院清淨(jìng)手術(shù)抗生素之使用量偏高院內(nèi)缺乏系統(tǒng)性收集外科預(yù)防性抗生素使用指標(biāo)設(shè)定目標(biāo)合理化外科預(yù)防性抗生素之使用不影響外科病患感染率為前提下掌握使用時(shí)效降低抗生素使用量國(guó)泰綜合醫(yī)院TQIP小組方 法立意取樣：TQIP

II

b

：CABG、THR、TKH、ATH、APP.

五種術(shù)式收案對(duì)象之預(yù)防性抗生素使用對(duì)象：醫(yī)療服務(wù)提供者方法：Cost

/

Effect

iveness

ratio國(guó)泰綜合醫(yī)院TQIP小組成本效益指標(biāo)使用量 ■

使用費(fèi)用使用時(shí)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國(guó)泰綜合醫(yī)院TQIP小組分科檢討改善國(guó)泰綜合醫(yī)院TQIP小組修正工作流程，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(shí)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(duì)共識(shí)主治醫(yī)師會(huì)議修正臨床路徑資訊公開適時(shí)回饋國(guó)泰綜合醫(yī)院TQIP小組醫(yī)品會(huì)議檢視每季趨勢(shì)比較世界、臺(tái)灣、同等級(jí)醫(yī)院檢討異常值，相關(guān)科部提出說明科主任會(huì)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(huì)議:加強(qiáng)共識(shí)使用量的降低TKR、THR、CABG、APP、ATH

各術(shù)式抗生素使用量與費(fèi)用曲線圖各術(shù)式抗生素使用量年度比較各術(shù)式抗生素費(fèi)用年度比較t-test

得到的p-value國(guó)泰綜合醫(yī)院TQIP小組89Mean+SD90Mean+SD91Mean

+SDp-valueQ1 34.27+13.06 27.37+12.510.61Q234.81+12.5631.54+14.670.34Q324.76+11.8628.29+11.070.65Q444.15+59.6420.82+10.300.13國(guó)泰綜合醫(yī)院TQIP小組TKR抗生素使用量89Mean+SD90Mean+SD91Mean

+SDp-valueQ14738.25+1897.362731.37+1192.040.39Q23522.42+1261.183144.23+1498.980.24Q32490.36+1228.742976.41+1146.790.80Q46358.30+8595.152154.23+1042.840.09TKR抗生素費(fèi)用國(guó)泰綜合醫(yī)院TQIP小組89Mean+SD90Mean+SD91Mean

+SDp-valueQ134.27+13.0627.26+13.470.85Q230.67+7.9927.70+15.800.30Q326.68+8.1929.82+11.810.08Q444.55+12.0732.82+35.920.10THR抗生素使用量國(guó)泰綜合醫(yī)院TQIP小組89Mean+SD90Mean+SD91Mean

+SDp-valueQ14738.25+1897.362751.70+1369.770.35Q23205.90+991.792809.52+1615.550.50Q32691.74+870.953091.06+1183.940.15Q4 9804.6+1808.384337.05+7752.430.08THR抗生素費(fèi)用國(guó)泰綜合醫(yī)院TQIP小組89Mean+SD90Mean+SD91Mean

+SDp-valueQ163.26+50.4245.58+14.290.11Q256.50+22.6848.83+21.510.63Q350.67+20.7839.31+20.120.62Q471.77+59.8658.50+28.120.31CABG抗生素使用量國(guó)泰綜合醫(yī)院TQIP小組899091 p-valueMean+SDMean+SDMean

+SDQ112402.98+16464.785318.92+2914.660.08Q28335.23+2908.485180.22+2111.060.08Q36072.93+32583964413.00+2517.470.42Q4國(guó)泰綜合醫(yī)院TQIP小組14891.34+26166.637665.00+4383.870.12CABG抗生素費(fèi)用89Mean+SD國(guó)泰綜合醫(yī)院TQIP小組90Mean+SD91Mean

+SDp-value0.00

＊

＊0.02

＊21.82+13.1423.53+9.8821.78+8.830.00

＊

＊Q1Q2Q3Q4 30.04+20.0529.70+39.0624.83+16.9120.78+17.4022.02+11.140.00

＊

＊APP抗生素使用量＊＊p＜.01＊p＜.0589Mean+SD90Mean+SD91 p-valueMean

+SDQ13972.84+7783.552177.07+1419.53 0.00＊＊Q22578.24+2263.222459.81+1115.65 0.00＊＊Q32106.53+3039.062199.52+1015.13 0.00＊＊Q4 4630.09+4354.192255.18+1286.890.00＊＊國(guó)泰綜合醫(yī)院TQIP小組APP抗生素費(fèi)用＊＊p＜.01國(guó)泰綜合醫(yī)院TQIP小組改善成效—使用時(shí)間掌握使用時(shí)效劃刀前30分鐘內(nèi)之預(yù)防性抗生素使用情況劃刀前2小時(shí)之預(yù)防性抗生素使用情況使用期限≤24小時(shí)TKRTHRCABGAPPATH改善成效—感染率國(guó)泰綜合醫(yī)院TQIP小組全院院內(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TKRTHRCABGAPPATH改善成效—每季全院院內(nèi)感染率季別國(guó)泰綜合醫(yī)院TQIP小組院內(nèi)感染率確無顯著差異成效使用時(shí)效改進(jìn)排序：ATH、TKR、THR、CABG、APP.使用量減少情況： Cost=

Cost1-Cost2ATH (-800)TKR (-3500)APP.(-2500)

CABG(-10000)

THR

(-6800)結(jié)果國(guó)泰綜合醫(yī)院TQIP小組CostTQIP年費(fèi)人事成本未增加教育訓(xùn)練成本未增加成本效益分析Effectiveness感染率無顯著差異平均抗生素使用量下降

平均抗生素使用費(fèi)用下降平均住院天數(shù)下降Cost

/

Effectiveness

Ratio國(guó)泰綜合醫(yī)院TQIP小組Co