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精细化临床路径管理在慢性阻塞性肺疾病急性加重患者抗菌药物治疗中的应用效果

Clinical pathway management for patients with acute exacerbation of chronic obstructive pulmonary disease undergoing antimicrobial medication

摘要:

目的 探讨实施精细化临床路径管理对慢性阻塞性肺疾病急性加重患者(AECOPD)抗菌药物合理应用的效果和意义.方法 判断抽样方法选取2017年4月8日至2018年12月31日北京市第六医院呼吸科住院的AECOPD患者126例为研究对象,按照抽签法随机分为同等数量的两组,试验组63例(精细化抗菌药物临床路径管理)及对照组63例(抗菌药物选择及应用时间以临床经验决定).对比观察两组患者的痰病原菌送检率及检出率,抗菌药物使用率、使用强度、疗程、费用、联合用药情况及患者住院时间、住院费用.结果 试验组痰病原学送检率及病原菌检出率[100.0% (63/63)比90.5% (57/63),x2=6.300;44.4%(28/63)比22.8%(13/57),x2=6.229]均高于对照组(均P<0.05),两组痰真菌检出率差异无统计学意义[15.9%(10/63)比14.0%(8/57),x2=0.079,P>0.05].试验组抗菌药物应用种类和抗菌药物使用率[9种比12种,85.7%(54/63)比96.8%(61/63),x2=4.881,P<0.05],单独一种抗菌药物的应用人次、DDD数及用药时间均少于对照组.试验组所有抗菌药物的累计应用人次[4.50 (0.25,14.75)]、抗菌药物消耗量(累计DDD数)[33.42 (0.66,96.00)]及用药时间[35.00(1.25,100.00)]均与对照组[7.00(2.25,16.0),52.86(25.90,137.7),59.50(24.50,139.00)]差异无统计学意义(Z值分别为-1.072、-1.387和-1.375,均P>0.05).试验组抗菌药物联合用药率[41.3%(28/63)]少于对照组[63.5%(40/63)](P=0.03),抗菌药物疗程[(7.63±3.95)d]、抗菌药物费用[1 157(745,2 002)元]、住院时间[(11.43±3.53)d]及住院费用[(13 020±5 511)元]均低于对照组[(12.84±4.45)d,t=-6.939;2063(1 534,2811)元,Z=-4.480;(16.65±3.99)d,t=-7.785;(19 621±4824)元,t=-7.121,均P<0.01],两组30d内急性加重率[9.5%(4/63)比6.3% (6/63)]差异无统计学意义(x2 =0.434,P=0.51).结论 AECOPD患者实施精细化临床路径管理后可有效提高痰病原菌送检率及检出率,降低抗菌药的使用率、使用强度、抗菌药物疗程、费用及联合用药率,降低患者住院时间及住院费用,未增加30 d内急性加重率,对临床抗菌药物合理应用提供了依据,对临床医疗费用控制起到一定的作用.

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abstracts:

Objective To evaluate the application of clinical pathway for patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) undergoing antibiotic administration.Methods One hundred and twenty six patients with AECOPD admitted from April 2017 to December 2018 were randomly divided into two groups:63 patients in study group (63) received antibiotics treatment according to the clinical pathway and other 63 patients in control group received antibiotics according to clinical experience.The rates of sample submission and positive sputum pathogens,the rates of antibiotic use and its intensity,course of treatment,drug cost and combined medication,length of stay and costs of hospitalization were analyzed and compared between two groups.Results The sample submission rate and the positive rate of sputum pathogens in study group were significantly higher than those in control group [100.0% (63/63) vs.90.5% (57/63),x2=6.300;44.4% (28/63) vs.22.8% (13/57),x2=6.229,P<0.05,respectively].The positive rate of fungi in sputum in study group was not different from that in control group [15.9% (10/63) vs.14.0% (8/57),x2=0.079,P>0.05].Types and rate of antibiotic usage in study group were lower than those in control group [9 vs.12;85.7% (54/63) vs.96.8% (61/63),x2=4.881,P<0.05].The administration time,defined daily use (DDD) and duration of single antibacterial drugs in study group were lower than those in control group.There were no significant differences in accumulate administration time [4.50 (0.25,14.75) vs.7.00 (2.25,16.0)],accumulative DDD [(33.42 (0.66,96.00) vs.52.86 (25.90,137.7)]and length of all antibiotics administration [(35.00 (1.25,100.00)d vs.59.50 (24.50,139.00)d] between study group and control group (Z=-1.072,-1.387,-1.375,respectively;all P>0.05).In study group,the combined antibiotics use rate was lower than that in control group [(41.3%(28/63) vs.(63.5%(40/63),P=0.03];the length [(7.63±3.95)d vs.(12.84±4.45) d,t=-6.939,P<0.01] and costs of antibiotics use [1 157 (745,2 002) Yuan vs.2 063 (1 534,2 811)Yuan,Z=-4.480,P<0.01],length of hospital stay [(11.43±3.53)d vs.(16.65±3.99)d,t=-7.785,P<0.01] and hospitalization expenses [(13 020±5 511) Yuan vs.(19 621±4 824) Yuan,t=-7.121,P<0,01] in study group were all significantly lower than those in control group.Acute exacerbation rate within 30 days in study group was not different from that in control group [9.5%(4/63) vs.6.3%(6/63),x2=0.434,P=0.51].Conclusion Application of clinical pathway management provides basis for rational use of antimicrobial drugs and for control of medical expenses for COPD patients with acute exacerbation.

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