Newell S D, Englert J, Box-Taylor A, Davis K M, Koch K E
Tupelo Neurology Clinic, Miss., USA.
Stroke. 1998 Jun;29(6):1092-8. doi: 10.1161/01.str.29.6.1092.
Ischemic stroke is a high-volume and financially draining diagnosis at this rural health system. The purpose of this clinical practice analysis was to identify resource utilization and clinical process inefficiencies and to promote clinically efficient, evidence-based improvements.
A retrospective analysis of medical record and financial databases of 356 patients with ischemic stroke was performed. The medical record data were adjusted for severity, and outliers were eliminated. The resources utilized by each physician were determined. Comparative graphs were prepared, presented, and discussed. The physicians implemented two types of changes: (1) alteration of resource utilization and consultation patterns and (2) support of clinical process improvement. In 1997, a follow-up analysis of 399 patients was performed.
The initial comparison of internists' to neurologists' patient populations found the following: patient age (75 versus 65 years), patient severity ratings (2.8 versus 2.5), length of stay (10.7 versus 8.8 days), costs ($7360 versus $6862), mortality rates (12.5% versus 8.9%), and aspiration pneumonia rate (8.5% versus 3.8%). A comparison of the 1995 analysis to the 1997 analysis revealed the following per patient resource utilization decreases (all P < 0.05): chemistry laboratory, 2.65 to 1.95 studies; intravenous fluids, 2.85 to 1.85 L; oxygen use, 6.06 to 2.75 U; and nifedipine use, 1.62 to 0.33 capsules. The clinical process improvements resulted in the following overall outcomes (all P < 0.05 except mortality): length of stay (7.2 days), nonadjusted costs ($6246), mortality (6.5%), and rates of pneumonia (2.7%).
Objective analysis of resource utilization resulted in physicians changing their individual management of stroke and collectively supporting clinical process changes that improved clinical and financial outcomes.
在这个农村卫生系统中，缺血性中风是一种高发病率且耗费资金的疾病诊断。本临床实践分析的目的是识别资源利用和临床流程中的低效情况，并推动临床高效、基于证据的改进。
对356例缺血性中风患者的病历和财务数据库进行回顾性分析。对病历数据进行严重程度调整，并剔除异常值。确定每位医生使用的资源。绘制、展示并讨论比较图表。医生实施了两种类型的改变：（1）资源利用和会诊模式的改变；（2）支持临床流程改进。1997年，对399例患者进行了随访分析。
对内科医生和神经科医生的患者群体进行的初始比较发现以下情况：患者年龄（75岁对65岁）、患者严重程度评分（2.8对2.5）、住院时间（10.7天对8.8天）、费用（7360美元对6862美元）、死亡率（12.5%对8.9%）以及吸入性肺炎发生率（8.5%对3.8%）。将1995年的分析与1997年的分析进行比较，结果显示每位患者的资源利用有以下降低（所有P<0.05）：化学实验室检查，从2.65项降至1.95项；静脉输液，从2.85升降至1.85升；氧气使用，从6.06单位降至2.75单位；硝苯地平使用，从1.62粒降至0.33粒。临床流程的改进带来了以下总体结果（除死亡率外所有P<0.05）：住院时间（7.2天）、未调整费用（6246美元）、死亡率（6.5%）以及肺炎发生率（2.7%）。
对资源利用的客观分析促使医生改变其对中风的个体管理方式，并共同支持临床流程的改变，从而改善了临床和财务结果。
