医疗意外险第三方数据对医疗质量监测作用研究  

Study on the role of third-party data of medical accident insurance in medical quality monitoring

作　　者：张波 许学敏[3] 赵铁夫[1] 王娜[1] 彭洁[1] 田雪迪 冯岩 孙建国 ZHANG Bo;XU Xuemin;ZHAO Tiefu;WANG Na;PENG Jie;TIAN Xuedi;FENG Yan;SUN Jianguo(Beijing Anzhen Hospital,Capital Medical University,Beijing,100029,PRC)

机构地区：[1]首都医科大学附属北京安贞医院,北京市100029 [2]中国人民财产保险有限公司北京市分公司,北京市100120 [3]首都医科大学附属北京安贞医院医患办,北京市100029

出　　处：《中国医院》2022年第4期57-58,共2页Chinese Hospitals

基　　金：北京市医院管理局“培育”项目(PG2019013)。

摘　　要：目的:探讨医疗意外险第三方数据对医疗质量监测作用。方法:选取某医院心脏外科2017-2020年接受心外科手术患者为研究对象,以手术死亡率为切入点,比较医院内部上报数据和第三方数据2种方式监测结果的灵敏度和总体符合率;将投保率、保险认定死亡率和真实死亡率建立回归方程,从理论上估测保险认定死亡率接近真实死亡率时所需要的医疗意外险投保率。结果:与实际数据比较,第三方数据的灵敏度和诊断符合率均高于医院内部上报数据;当投保率高于60.86%时,第三方数据的死亡率接近实际数据。结论:当投保率达到一定水平时,来源于医疗意外险第三方数据在医疗质量监测中的灵敏度和总体符合率高于医院内部的上报数据,可将其作为医疗质量监测的有益补充。Objective:To explore the role of third-party data from medical accident insurance in medical quality monitoring.Methods:The patients who underwent cardiac surgery in Beijing Anzhen Hospital Affiliated to Capital Medical University from 2017 to 2020 were selected as the research object.The surgical mortality was selected as the starting point,and the sensitivity and overall coincidence rate of the monitoring results were compared between the internal data reported by the hospital and the thirdparty data;The regression equation is established for the insured rate,the insurance recognized mortality and the real mortality,and the insured rate of medical accident insurance required when the insurance recognized mortality is close to the real mortality is estimated theoretically.Results:Compared with the real world data,the sensitivity(98.75%±0.44%vs.64.04%±4.21%,P=0.000)and diagnostic coincidence rate(99.98%±0.01%vs.99.53%±0.01%,P=0.000)of the third-party data were higher than those reported by the hospital;When the insurance rate is higher than 60.86%,the mortality rate of the third-Party data is close to the real world data.Conclusion:When the coverage rate reaches a certain level,the sensitivity and overall compliance rate of the third point data from medical accident insurance claims in medical quality monitoring are higher than the traditional reported data of the hospital,which is worthy to be used as a useful supplement to medical quality monitoring.

关 键 词：医疗意外险 医疗质量 心脏外科 

分 类 号：R197.3[医药卫生—卫生事业管理]