品质改善成本效益-TQIP对外科预防性抗生素使用之影响

品質改善成本效益—

TQIP對外科預防性抗生素使用之影響ModelofaNationalHealthSystemHealthResultManagementOrganizationEconomicsupportResourcesServicesdeliveryHealthNeedsLimitedMedicalResources

vs.

OptimalHealthcareQualityLowCostvsHighEffectiveness

=Cost-effective(Therelationshipbetweenachievingcertainobjectivesandconsumptionofresources，costsvsoutcomes)EfficacyvsEffectiveness

Efficacy

isameasureoftheextenttowhichobjectives(result,cure)areachievedinreal

practicesettings.

Effectiveness

concernsgeneralizabilityofresultsoftreatment.HealthcareCostas%ofGNP13.4%-13.7%(5.4%Taiwan)USHealthcareCostin$$1.491TrillionPredictedincreaseof10%in20002.2Trillionby2008Cost--EffectivenessCLIENTPROVIDERPAYERSOCIETYCostofSurgicalOperationsExpendablesuppliesInstrumentsEquipmentImplantsFacilityCostEmployeesPre-optestingExpendablesuppliesLaparotomypackageGown,glovesandtowelsPrepEKGandoxygenfingerpadsAnesthesiagasesandmasksLocalanesthesiaandantibioticsMedical(Year2000)Hospital40%Professional42%Pharmacy18%(25%Taiwan)FullTimeEmployeeReceptionistPreopnurseCirculatingnurseSurgicaltechRecoveryroomnurseORsupervisorCOOfacility-$22/hrfor9-9/5hrsforeachcase$209/hr.foreverycase品質成本預防性成本：教育訓練,資格認定,指標建立,治療共識評鑑成本：定期監測,稽核,滿意度調查內部失敗成本：執行前或執行中失敗之成本外部失敗成本：錯誤導致醫療糾紛與賠償Effectiveness-Outcomemeasurement病人方面：Auditofpatientoutcomes(併發症,死亡率,住院日,病假日,回復工作能力,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使用之影響抗生素費用是全院藥品費用支出之大宗合理使用抗生素可避免藥物副作用89年衛生署提出本院清淨手術抗生素之使用量偏高院內缺乏系統性收集外科預防性抗生素使用指標設定目標合理化外科預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效降低抗生素使用量方

法立意取樣：TQIPIIb：CABG、THR、TKH、ATH、APP.五種術式收案對象之預防性抗生素使用對象：醫療服務提供者方法：Cost/Effectivenessratio成本效益指標使用量■使用費用使用時間（過程）院內感染率（結果）平均住院天數（結果）Independentt-test分科檢討改善修正工作流程，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:加強共識使用量的降低TKR、THR、CABG、APP、ATH各術式抗生素使用量與費用曲線圖各術式抗生素使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抗生素之使用季別加入TQIP使用支數金額TKR抗生素使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+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抗生素費用改善情況—THR抗生素之使用季別加入TQIP使用支數金額THR抗生素使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+13.470.85Q230.67+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+1183.940.15Q49804.6+1808.384337.05+7752.430.08THR抗生素費用改善情況—CABG抗生素之使用季別加入TQIP使用支數金額CABG抗生素使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+21.510.63Q350.67+20.7839.31+20.120.62Q471.77+59.8658.50+28.120.31CABG抗生素使用量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抗生素之使用季別加入TQIP使用支數金額APP抗生素使用量同期比較季別支數/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抗生素使用量＊＊p＜.01＊p＜.05899091p-valueMean+SDMean+SDMean+SDQ1Q2Q3Q44630.09+4354.193972.84+7783.552578.24+2263.222106.53+3039.062255.18+1286.892177.07+1419.532459.81+1115.652199.52+1015.130.00＊＊0.00＊＊0.00＊＊0.00＊＊APP抗生素費用＊＊p＜.01改善情況—ATH抗生素之使用季別加入TQIP使用支數金額ATH抗生素使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/人次改善成效—使用時間掌握使用時效劃刀前30分鐘內之預防性抗生素使用情況劃刀前2小時之預防性抗生素使用情況使用期限24小時TKRTHRCABGAPPATH百分比II-b:SurgicalProphylaxisRate-KneeArthroplastySurgicalProphylaxisWithin30minutesPriortoIncision(2001q1)(8/18)(8/26)(13/31)(13/20)(13/25)百分比II-b:SurgicalProphylaxisRate-HipArthroplastySurgicalProphylaxisWithin30minutesPriortoIncision(2001q1)(5/15)(3/20)(7/26)(10/30)(6/26)百分比II-b:SurgicalProphylaxisRate-CABGSurgicalProphylaxisWithin30minutesPriortoIncision(2001q1)(5/22)(12/36)(3/15)(4/25)(7/28)百分比II-b:SurgicalProphylaxisRate-AppendectomySurgicalProphylaxisWithin30minutesPriortoIncision(2001q1)(9/79)(5/104)(3/101)(6/70)(5/68)百分比II-b:SurgicalProphylaxisRate-AbdominalHysterectomySurgicalProphylaxisWithin30minutesPriortoIncision(2001q1)(33/57)(43/57)(50/68)(34/36)(34/43)百分比II-b:SurgicalProphylaxisRate-KneeArthroplastySurgicalProphylaxisWithin2hoursPriortoIncision(17/22)(17/18)(25/26)(27/31)(20/20)(24/25)百分比II-b:SurgicalProphylaxisRate-HipArthroplastySurgicalProphylaxisWithin2hoursPriortoIncision(18/22)(12/15)(19/20)(21/26)(30/30)(22/26)百分比II-b:SurgicalProphylaxisRate-CABGSurgicalProphylaxisWithin2hoursPriortoIncision(31/33)(21/22)(35/36)(15/15)(25/25)(28/28)百分比II-b:SurgicalProphylaxisRate-AppendectomySurgicalProphylaxisWithin2hoursPriortoIncision(80/87)(67/79)(92/104)(88/101)(61/68)(68/70)百分比II-b:SurgicalProphylaxisRate-AbdominalHysterectomySurgicalProphylaxisWithin2hoursPriortoIncision(50/57)(73/74)(50/57)(67/68)(35/36)(43/45)百分比II-b:SurgicalProphylaxisRate-AbdominalHysterectomySurgicalProphylaxisfor24hoursorless(2001q1)(17/57)(53/57)(5