2021年国家医疗质量安全改进目标说明

1目标一:提高急性ST段抬高型心肌梗死再灌注治疗率。1.1目标简述①急性心肌梗死是导致我国居民死亡的首要病种,提高急性ST段抬高型心肌梗死(STEMI)患者再灌注治疗率对降低急性STEMI患者的致残率及死亡率、改善患者生活质量、减轻社会和家庭负担具有重要意义。②急性ST段抬高型心肌梗死再灌注治疗,是指对发病12 h内的急性STEMI患者给予经皮冠状动脉介入治疗(PCI)或静脉溶栓治疗,首选PCI治疗。     

全国急性ST段抬高型心肌梗死（STEMI）医疗服务与质量安全报告分析

目的 了解我国急性ST段抬高型心肌梗死(STEMI)医疗服务与质量安全工作现状，为急性STEMI医疗质量持续改进提供参考。方法 基于国家单病种质量管理与控制平台，收集并分析2019年-2020年二、三级医院急性STEMI相关数据，利用SAS 9.4软件对数据进行分析。结果 2020年急性STEMI患者平均住院日二、三级医院间与地区间均有所差异；各地区住院费用相比2019年呈减少趋势(P<0.05)。过程指标中，检查及循证药物使用情况2020年较2019年有所改善，发病12 h内到院患者再灌注治疗率总体为72.1%,其中到院90 min内进行直接PCI的比例为43.4%,在三级医院较高，溶栓患者到院30 min内溶栓治疗的比例为35.3%,二级医院高于三级医院。结局指标中，2020年住院死亡率总体为1.8%,三级医院2020年住院死亡率较2019年增加明显(P<0.05),各地区住院死亡率存在差异。结论 我国急性STEMI医疗服务质量地区间和医疗机构级别间存在差异。医疗机构应持续关注急性STEMI过程指标及结局指标，国家心血管病医疗质量控制中心应继续开展医疗质量改进行动，推动...     

基于评价指标的慢性心力衰竭治疗质量的趋势与变异

目的 分析2011-2017年慢性心力衰竭(HF)治疗质量评价指标使用率变化趋势,计算HF治疗质量综合得分,获得综合质量变化趋势及变异,为提高HF治疗质量提供依据。方法 选择HF治疗指南I类推荐的治疗质量评价指标12项,在单病种质量管理与控制平台中提取数据,计算HF评价指标使用率,基于分母权重法计算每年治疗质量综合得分及变异,并进行趋势性检验。结果 与2011年相比,12项治疗质量指标中,左心室功能评价使用率增幅最大,健康教育使用率下降最大,趋势性检验有统计学意义。2011年至2017年间,医院综合得分中位数随时间增大(0.77～0.81),四分位数间距随时间有增加趋势。结论 2011-2017年间,我国HF的多数治疗质量指标使用率有显著上升趋势,少数指标使用率下降,医院治疗质量综合得分升高,但医院间变异扩大,提示进一步提升HF治疗质量同时应关注医院间的质量差异。     

厦门市居民急性心肌梗死死亡的流行病学研究

目的探讨厦门市居民急性心肌梗死死亡变化趋势,为厦门市急性心肌梗死综合防治工作提供依据。方法收集整理2005-2014年厦门市居民急性心肌梗死死亡资料,计算死亡率等评价指标,用多因素Logistic回归分析急性心肌梗死死亡的影响因素。结果 2005-2014年,厦门市居民急性心肌梗死死亡率31.73/10万,各年男性标化死亡率始终高于女性;死亡率随着年龄的升高逐渐升高,死亡年龄中位数为77岁;10年间死亡率处于较平稳水平(P﹥0.05)。男性(OR=1.67,95%CI:1.59~1.76)、生活在农村(OR=0.67,95%CI:0.63~0.70)和2010-2014年时间段(OR=1.08,95%CI:1.03~1.14)、年龄越大(OR=1.76,95%CI:1.75~1.78)可能是急性心肌梗死死亡的危险因素。结论厦门市急性心肌梗死死亡率居高不下,应以农村、男性、老年人群为重点关注对象,重视急性心肌梗死防治工作。     

多维项目反应理论模型在疾病治疗质量评价中的应用

目的利用多维项目反应理论模型评价医院急性心肌梗死和慢性心力衰竭的治疗质量。方法基于多维项目反应理论建立医院急性心肌梗死治疗质量、慢性心力衰竭治疗质量和评价指标使用概率三者的函数关系,利用贝叶斯估计法和马尔可夫链蒙特卡洛(MCMC)方法估计模型参数。结果建立了评价急性心肌梗死和慢性心力衰竭治疗质量的多维项目反应理论模型;通过模型获得了两个相关疾病治疗质量的估计值,同时进行治疗质量的排序;两个相关疾病治疗质量估计值的相关系数为0.789,P0.0001。结论多维项目反应理论模型适用于相关疾病的治疗质量评价,模型能同时估计多个疾病的治疗质量,并将不同疾病治疗质量间相关性整合进模型,估计更可靠、准确。     

基层医院急性ST段抬高型心肌梗死再灌注治疗策略

随着我国人民生活水平的提高和生活方式的改变,冠心病成为死亡的首要原因,其中急性心肌梗死(AMI)具有死亡率高、致残率高、发病凶险等特点,日益受到人们重视。AMI分为ST段抬高型心肌梗死(STEMI)和非ST段抬高型心肌梗死,其中STEMI最为危重。根据相关数据统计,基层医院约接诊70%STEMI患者,成为救治STEMI的主战场,由于医疗条件的限制,溶栓治疗是目前基层医院实施STEMI再灌注治疗的必然选择,不过由于治疗策略欠缺规范,导致基层医院的STEMI再灌注治疗具有一定的困难。为快速有效治疗STEMI患者,本文结合《2010急性ST段抬高型心肌梗死诊断和治疗指南》、《2015急性ST段抬高型心肌梗死诊断和治疗指南》,及相关文献将基层医院STEMI再灌注治疗的策略作如下总结。     

尿激酶联合低分子肝素治疗急性ST段抬高型心肌梗死25例临床疗效观察

目的观察尿激酶联合低分子肝素治疗急性ST段抬高型心肌梗死（STEMI）患者临床疗效。方法将45例急性STEMI患者随机分为2组：对照组（20例）给予常规控制血压、血管扩张剂、促进心肌代谢等药物应用,观察组（25例）在常规用药的基础上,给予尿激酶联合低分子肝素应用。采用病死率、有效率及并发症发生率等指标比较两组患者的临床疗效。结果治疗后,观察组冠状动脉再通率和有效率高于对照组,而病死率和并发症发生率低于对照组。结论尿激酶联合低分子肝素治疗急性STEMI患者疗效肯定。     

老龄急性ST段抬高性心肌梗死患者急诊介入治疗的临床分析

目的评价老龄急性ST段抬高性心肌梗死(STEMI)患者急诊经皮冠状动脉介入(PCI)治疗的临床疗效。方法分析66例老龄急性STEMI患者临床资料,分为急诊PCI治疗组和药物保守治疗组,比较两组住院时间及住院期间心血管事件(不稳定型心绞痛、心功能不全、心律失常、再次心肌梗死、急诊冠状动脉旁路移植术及死亡)的发生情况。结果急诊PCI治疗组血管造影成功率为100%,介入治疗成功率为98%。急诊PCI治疗组与药物保守治疗组相比,住院时间分别为(7.75±1.80)d和(10.53±3.45)d(P<0.05);住院期间不稳定型心绞痛发生率分别为12.5%和34.6%(P<0.05);心功能不全发生率分别为22.5%和57.7%(P<0.05);心律失常发生率分别为17.5%和38.5%(P<0.05);病死率分别为5.1%和23.1%(P<0.05)。两组再次心肌梗死发生率及行急诊冠状动脉旁路移植术的比例差异无统计学意义。结论对于老龄急性STEMI患者行急诊PCI治疗是安全有效的,可以减少住院期间心血管事件的发生。     

替罗非班治疗急性ST段抬高型心肌梗死行直接PCI患者的临床疗效

目的 评价替罗非班治疗急性ST段抬高型心肌梗死(STEMI)患者行直接PCI的有效性、安全性.方法 将150例STEMI患者按就诊顺序分为75例观察组(加用替罗非班)和75例对照组,所有患者均正规使用肝素(包括低分子肝素)、盐酸氯吡格雷、阿斯匹林.疗程48 h,观察指标为出血并发症、血小板聚集率(MAR).终点事件是一个月内的主要心脏不良事件(MACE).结果 观察组较对照组给药后24 h MAR明显减少(P<0.05),而出血并发症和一个月MACE率差异均无统计学意义(P>0.05).结论 替罗非班治疗STEMI行直接PCI安全、有效.     

46例急性心肌梗死患者的临床护理体会

目的：探讨综合护理措施在急性心肌梗死患者救治中的应用价值。方法：对46例在笔者所在医院抢救、治疗的急性心肌梗死患者进行了一系列的综合护理措施,评价其效果。结果：44例患者治愈或好转出院,死亡2例,死亡率4.3%。结论：积极有效的综合护理措施对于降低急性心肌梗死患者的死亡率,改善生活质量具有重要意义。     

Comparing a multivariate response Bayesian random effects logistic regression model with a latent variable item response theory model for provider profiling on multiple binary indicators simultaneously

Provider profiling entails comparing the performance of hospitals on indicators of quality of care. Many common indicators of healthcare quality are binary (eg, short-term mortality, use of appropriate medications). Typically, provider profiling examines the variation in each indicator in isolation across hospitals. We developed Bayesian multivariate response random effects logistic regression models that allow one to simultaneously examine variation and covariation in multiple binary indicators across hospitals. Use of this model allows for (i) determining the probability that a hospital has poor performance on a single indicator; (ii) determining the probability that a hospital has poor performance on multiple indicators simultaneously; (iii) determining, by using the Mahalanobis distance, how far the performance of a given hospital is from that of an average hospital. We illustrate the utility of the method by applying it to 10 881 patients hospitalized with acute myocardial infarction at 102 hospitals. We considered six binary patient-level indicators of quality of care: use of reperfusion, assessment of left ventricular ejection fraction, measurement of cardiac troponins, use of acetylsalicylic acid within 6 hours of hospital arrival, use of beta-blockers within 12 hours of hospital arrival, and survival to 30 days after hospital admission. When considering the five measures evaluating processes of care, we found that there was a strong correlation between a hospital's performance on one indicator and its performance on a second indicator for five of the 10 possible comparisons. We compared inferences made using this approach with those obtained using a latent variable item response theory model.     

我国中部某地区急性ST段心肌梗死医疗质量研究

目的研究我国中部某地区急性ST段心肌梗死住院病例医疗质量,寻找原因,并针对性改进。方法从中国胸痛中心总部数据库获取2018年1月-6月我国中部某地区5家医院1 172例STEMI住院患者数据,以是否入院90 min内实施PCI、是否绕行CCU、是否进行双联抗血小板治疗、首次医疗接触时间至双联抗血小板治疗时间是否小于等于10min、是否入院24h内强化他汀治疗、是否出院后继续使用β阻滞剂、是否出院后继续使用他汀类药物、是否院内死亡8个变量为评价指标,建立线性概率模型控制年龄和性别后,分析不同医院间的医疗质量     

Organizational resiliency: how top-performing hospitals respond to setbacks in improving quality of cardiac care

Despite substantial improvement in recent years in hospital performance in many quality measures for acute myocardial infarction (AMI), national performance lags in a key publicly reported quality indicator for AMI--door-to-balloon time, the period from patient (with ST-segment elevation myocardial infarction or STEMI) arrival to provision of percutaneous coronary intervention or balloon angioplasty. Previous research has elucidated distinguishing features of hospitals that routinely achieved recommended door-to-balloon times for patients with STEMI. However, what has not been fully explored is how top-performing hospitals handle setbacks during the improvement process. In this study, we used qualitative methods to characterize the range of setbacks in door-to-balloon improvement efforts and the strategies used to address these barriers among hospitals that were ultimately successful in reducing door-to-balloon time to meet clinical guidelines. Setbacks included (1) failure to anticipate and address implications of initial changes in door-to-balloon processes for the system as a whole; (2) tension between and within departments and disciplines, which needed to gain consensus about how to reduce door-to-balloon time; and (3) waning attention to door-to-balloon performance as a top priority after the perceived goal of reducing treatment times had been reached. Our findings demonstrate key aspects of technical capacity, organizational culture, and environmental conditions that were factors in maintaining improvement efforts despite setbacks and hence may be critical to sustaining top performance. Understanding how top-performing hospitals recognize and respond to setbacks can help senior management promote organizational resiliency, leading to an environment in which learning, growth, and quality improvement can be sustained.     

基于变异系数赋权与功效系数的医院综合评价

目的 为了解湛江市二级综合医院的医疗质量状况,对9家医院综合水平进行排序,找出某院与同行的差距,以及需要改进之处,为该院的发展提供决策依据.方法 从国家卫生统计信息网络直报系统提取2009年湛江市九家二级医院的直报数据,根据广东省卫生厅采用的指标公式整理并提取病床使用率、病床周转次数、平均住院日、病床工作日、有效率、病死率、住院危重病人抢救成功率、急诊抢救成功率、三日确诊率、入出诊断符合率、药品比例、平均每医生收治住院病人数、平均每医生负担诊疗人次、平均每诊疗人次医疗费、出院者平均每天住院医疗费等15个有代表性的医疗质量、效率指标.使用变异系数赋权与功效系数法,对这九家医院的上述指标进行综合评价.首先运用Excel求出标准差及变异系数,根据指标包含的信息确定权重,再计算功效系数,然后采用加权几何平均法计算出总功效系数,对结果进行排序.结果 A～I代表的九家医院医疗质量总功效系数分别为68.7、79.1、71.9、86.5、86.0、79.5、87.6、83.3、90.3.I单位平均住院日等4个指标排名第1,2个指标排第2,综合水平名列前茅;G单位病死率等3个指标排第1,平均住院日排第2,3个指标排第3,综合水平第2;A单位虽然出院者平均每天住院医疗费排第1,有效率排第2,但是病床使用率等权重较大的8个指标排在第8或9,综合水平排名最后.结论 A单位在医疗技术培训、抢救水平、外科及儿科建设、宣传等方面要加大力度,提升医疗质量.     

Myocardial Infarction Registry--2010. Experience and first results in Hungary

Authors present the methodology and first data of Hungarian Myocardial Infarction Register Pilot Study started 1st of January, 2010. The aim of the study is to collect epidemiological data on myocardial infarction, to examine the natural history of the disease and to investigate the main characteristics on patient care in the pilot area. The program is using standardized diagnostic criteria and predefined electronic data record forms (eCRF). The pilot area consists of 5 districts in the capital, and Szabolcs-Szatmár-Bereg county. The area has 997 324 inhabitants. Eight cardiology departments, 5 with heart catheterization facility (C) in Budapest, four hospitals with one C in Szabolcs-Szatmar-Bereg county have been responsible of the patients' care. After starting the program 16 other hospitals joined the program from different parts of Hungary. Between 1st of January 2010 and 1st of May 2011 4293 patients were registered, among them 52.1% with ST segment elevation myocardial infarction (STEMI), 42.1% with non-ST segment elevation myocardial infarction (NSTEMI), while 3% of the patients had unstable angina, and 2.8% of the cases had other diagnosis or the hospital diagnosis was missing in the eCRF. Authors compare the patients care with STEMI in five districts of Budapest and Szabolcs-Szatmár-Bereg county. In Budapest 79.7% of the 301 STEMI patients were treated in C and 84.6% of them were treated with primary percutaneous intervention (pPCI). In Szabolcs-Szatmár-Bereg county 402 patients were registered with STEMI, 62.9% of them were treated in C, where 77% of them were treated with pPCI. The drugs (beta blockers, ACE inhibitors, statins) important for secondary prevention were given more often to patients treated in the capital, however no difference was found in the platelet aggregation inhibitors therapy. Hospital mortality of STEMI patients was 8% in the capital, and 10% in Szabolcs- Szatmár-Bereg county. Authors conclude that the web based myocardial infarction register is feasible and important to have reliable data on patient care and a necessary quality control tool. Authors propose to broaden this pilot program and to start a nationwide myocardial infarction register.     

基于胸痛中心的区域协同救治体系建设实践*

为改变我国急性ST段抬高心肌梗死(STEMI)患者的救治现状,国内以广州军区总医院及上海胸科医院为首,相继成立了基于胸痛中心的STEMI区域协同救治体系。嘉定区中心医院自2016年5月12日成立嘉定区胸痛中心,截止2018年4月30日共收治了9 002例胸痛患者,其中STEMI患者363例,急性非ST段抬高心肌梗死(NSTEMI)患者203例。通过医疗资源整合、建立区域协同快速救治体系及优化院内胸痛救治流程,有效缩短了患者门-球(Door to Balloon,D2B)时间,提高了急性心肌梗死救治成功率。     

From Multiple Quality Indicators of Breast Cancer Care Toward Hospital Variation of a Summary Measure

ObjectivesTo improve quality in breast cancer care, large numbers of quality indicators are collected per hospital, but benchmarking remains complex. We aimed to assess the validity of indicators, develop a textbook outcome summary measure, and compare case-mix adjusted hospital performance.MethodsFrom a nationwide population-based registry, all 79 690 nonmetastatic breast cancer patients surgically treated between 2011 and 2016 in 91 hospitals in The Netherlands were included. Twenty-one indicators were calculated and their construct validity tested by Spearman’s rho. Between-hospital variation was expressed by interquartile range (IQR), and all valid indicators were included in the summary measure. Standardized scores (observed/expected based on case mix) were calculated as above (>100) or below (<100) expected. The textbook outcome was presented as a continuous and all-or-none score.ResultsThe size of between-hospital variation varied between indicators. Sixteen (76%) of 21 quality indicators showed construct validity, and 13 were included in the summary measure after excluding redundant indicators that showed collinearity with others owing to strong construct validity. The median all-or-none textbook outcome score was 49% (IQR 42%-54%) before and 49% (IQR 48%-51%) after case-mix adjustment. From the total of 91 hospitals, 3 hospitals were positive (3%) and 9 (10%) were negative outliers.ConclusionsThe textbook outcome summary measure showed discriminative ability when hospital performance was presented as an all-or-none score. Although indicator scores and outlier hospitals should always be interpreted cautiously, the summary measure presented here has the potential to improve Dutch breast cancer quality indicator efforts and could be implemented to further test its validity, feasibility, and usefulness.     

基于收支结构变动度模型的专科医院发展特点与挑战分析

目的：分析样本专科医院2017—2021年收支结构变化的特征及趋势,论证公立医院综合改革实践及其相关政策对专科医院可持续发展的积极作用。方法：借助2017—2021年样本专科医院财务收入和支出相关指标与数据,利用结构变动度模型进行系统分析。结果：医疗服务收入占比持续提升,药品、卫生材料、检查和化验收入占比持续下降,且政府财政补助占比也呈下降趋势。结论：公立医院综合改革实践成效明显,促进了专科医院的转型发展,但需进一步完善医院综合改革措施,有效地保障公立医院的可持续发展。     

Discriminating quality of hospital care in the United States.

BACKGROUND AND OBJECTIVE: The Centers for Medicare and Medicaid Services (CMS) report quality of care for patients hospitalized with acute myocardial infarction (AMI), congestive heart failure (CHF), and community-acquired pneumonia (CAP) with the intention of rewarding superior performing hospitals. The aim of the study was to compare identification of superior hospitals for providing financial rewards using 2 different scoring systems: a latent score that weights individual clinical performance measures according to how well each discriminated hospital quality and a raw sum score (the system adopted by CMS). METHODS: This observational cohort study used 2761 acute care hospitals in the United States reporting AMI clinical performance measures, 3271 reporting CHF measures, and 3714 hospitals reporting CAP measures. For each clinical condition, the main outcome measures included the average raw sum score, the latent score estimated from an item response theory (IRT) model, and the percentage of false negative superior designations made on the basis of raw sum scores relative to latent scores. RESULTS: The average raw sum score was highest for AMI (88.8%) and lower for CHF (73.1%) and CAP (76.3%). AMI measures were equally nondiscriminating of hospital quality; hospital discharge instruction was most discriminating of CHF quality; pneumococcal vaccination was most discriminating of CAP quality. False negative rates varied 2-fold: AMI (10%), CHF (16%), and CAP (24%). CONCLUSIONS: Neither the AMI raw sum score nor latent score discriminates hospital quality due to ceiling effects. Current methods for aggregating measures result in different hospital superior designations than those based on the latent score. Organizations that financially reward hospitals on the basis of such scores need to assess predictive validity of scores and determine a minimum level of classification accuracy.     

2015年-2017年全国三级医院护理质量分析

目的分析2015年-2017年我国三级医院护理质量现状,为质量持续改进提供依据。方法从国家护理质量数据平台提取2015年-2017年护理质量相关数据,分析各指标数据的变化情况。结果（1）截止2017年,所有指标的完整性均超过98%。（2）床护比、护患比与24小时平均护理时数3项指标3年均保持相对稳定。（3）2015年-2017年三级医院本科及以上护士占比增长明显,3年增加8.12%;5年及以上年资护士占比稳步提升,3年增加5.36%;2015年-2017年三级医院护士离职率稳步下降,3年下降0.24%。（4）2015年-2017年三级医院住院患者身体约束率中位数分别为1.38%、1.36%、1.60%,呈现波动变化,2017年增长较为明显。（5）护士执业环境中的“医院管理参与度”“薪酬待遇”与“社会地位”等维度得分较低。结论（1）经过两年护理敏感质量指标理念与数据收集的培训,三级医院护理质量指标数据变异度逐渐减小,数据完整性与可靠性得到提升;（2）护理人员绝对数量的增加并未改善护理人员相对不足的现状;（3）护理人力结构得到优化,队伍稳定性增强;（4）约束、跌倒等指标逐年升高,侧面印证了数据上报文化逐步形成和数据逐渐趋于真实与可靠;（5）护士执业环境测评结果表明,薪酬待遇及社会地位是制约护理行业的关键因素。