临床路径变异控制的思考  

Thinking on the Variation Control of Clinical Pathways

作　　者：郭顺萍[1] 刘豫瑞[1] 蒋文欣[1] 郑振佺[2] 

机构地区：[1]福建医科大学附属第一医院,福州市350005 [2]福建医科大学公共卫生学院,福州市350004

出　　处：《中国病案》2016年第1期18-21,36,共5页Chinese Medical Record

摘　　要：目的分析胃癌临床路径病例的变异原因,提出相应对策,为临床路径变异的干预管理提供理论依据与经验支持。方法对197例实施临床路径管理的胃癌病例进行回顾性分析,按照变异来源和变异管理难易程度调查变异发生情况,并应用二分类多变量logistic回归分析退出路径的变异危险因素。结果完成路径组疾病转归因素占32.93%,患者需求因素占2.24%,医护因素占54.31%,医院系统因素占10.52%;其中可控变异为64.83%,不可控变异为35.17%。退出路径组疾病转归因素占61.29%,患者需求因素占22.58%,医护因素为16.13%;其中不可控变异83.87%,可控变异16.13%。二分类多变量logistic回归分析显示:胃癌分期(OR 72.74,P<0.001)、患者配合程度(OR 12.37,P<0.001)以及严重术后并发症(OR 4.29,P<0.05)是胃癌患者退出临床路径的主要影响因素。结论胃癌临床路径完成组以可控变异为主,可通过完善路径文本、提高认识、加强培训并制定长期有效的监督检查及奖惩措施,同时加快信息平台建设最大限度减少可控变异;退出组以不可控变异为主,可通过"择日住院"、加强医患沟通以及"分支路径"等措施减少导致退出路径的严重变异,最终达到临床路径质量持续改进的目的。Objective To analyze the variation reasons of the clinical pathway of gastric cancer cases, propose relevant countermeasures to provide the theoretical basis and experience support for the intervention management of clinical pathways variation. Methods To conduct a retrospective analysis on 197 cases of gastric cancer patients with clinical pathway management, investigate the variation situation according to the variation sources and variation management difficulty level, and analyze the risk factors for the variation of the exit route with the application of two multivariate logistic regression analysis. Results In the path completion group,variation in the incidence of disease outcome factors was 32.93%, 2.24% for the patients＇ need,54.31% for the medical personnel and 10.52% for the hospital system,among which the controllable variance was 64.83%,and the non controllable variation was 35.17%.In the path out group, variation in the incidence of disease outcome factors was61.29%,22.58% for the patients＇ need,16.13% for the medical personnel,among which the controllable variance was83.87%, and the non controllable variation was16.13%.Two multivariate logistic regression analysis showed that staging of gastric cancer（OR 72.74,〈0.001）,the degree of patient compliance（OR12.37,P〈0.001）, and patients with serious postoperative complications（OR 4.29,P〈0.05） were the main influencing factor of the clinical pathway in patients with gastric cancer. Conclusions Controllable variance were the main factors of variation in the clinical pathways completion group with gastric cancer, we could reduce the controllable variance to the largest extent through the improvement of text pathways, raising awareness, strengthening the training and developing long-term and effective supervision and incentive measures as well as speeding up the construction of information platform. The pathways out group dominated by uncontrollable variance, we could reduce serious variations through measures conducting ＂optional day

关 键 词：临床路径 变异 质量控制 对策 

分 类 号：R197.323[医药卫生—卫生事业管理]