摘要
研究背景
本课题研究是中央保健委员会专项科研课题---干部保健人群健康评估、早期预警、综合干预一体化服务体系研究(课题编号06H050)的子课题。大课题拟在原有工作基础上,探索构建符合本人群特点的健康管理、促进模式,探索和制定一系列相配套的规范化诊疗程序、综合防治措施和科学管理办法,为临床医疗的循证保健和规范防治提供理论依据和具有可操作性的工作指南,为决策机关制定医疗保健的宏观策略提供信息技术支撑和保障。本课题主要进行干部保健对象医疗质量的评价研究。作为国家投入了大量精力、财力、人力的干部保健工作,如何进行保健医疗质量评价,保健医疗质量水平如何,是管理者迫切需要了解的问题。
研究目的:
本研究以干部保健对象这一特殊人群为研究对象,充分利用循证医学方法,结合临床专家的诊疗经验,利用RAND专家评价法,探索创建一套评价干部保健医疗质量的指标体系,涵盖保健医疗服务中的预防、诊断、治疗、随访及健康教育5个方面,并利用某医院干部保健病房数据进行初步实证性研究,以期为干部保健工作提供保健医疗工作规范标准及质量评价工具,促进保健医疗质量的持续提高。
研究内容:
1、干部保健对象医疗质量评价指标体系的建立研究干部保健医疗质量评价的方法选择:结合干部保健人群的特点以及目前我国医疗质量评价的发展趋势,确定了以过程质量来进行保健医疗质量评价的主要方式。
干部保健人群疾病谱的确定:通过文献调查与病例查询,确定了目前我军保健人群的主要疾病谱。
干部保健对象医疗质量评价指标体系的建立:根据干部保健人群的主要疾病谱,查阅大量的相关疾病诊疗指南及诊疗规范,以可采集性为原则,提出了供专家评价的初筛指标;应用RAND专家小组评价法对干部保健医疗评价指标进行了筛选,确定了干部保健医疗质量评价体系的一级指标和二级指标。
2、干部保健对象医疗质量评价的实证研究利用上述指标体系对某医院干部保健病房2008.1-2009.6的部分抽样病例进行了查询及随访,对干部保健医疗质量进行了初步评价及分析,并提出了保健医疗质量改进意见。
研究结果:
1、建立了由两级指标组成的评价指标体系。一级指标共12个,主要由老年人群中常见的疾病状况和老年综合征组成,包括高血压、糖尿病、急性冠脉综合征、缺血性卒中、慢性阻塞性肺疾病、前列腺增生、社区获得性肺炎、心衰、疾病筛查及预防、抑郁、视力和跌倒。二级指标129个,指标由具体的诊疗过程组成,分为疾病筛查及预防、诊断、治疗、随访和健康教育5个方面,涵盖了保健对象卫生医疗服务的全过程。所有二级指标中,疾病筛查及预防指标11个,占8.5%;诊断性指标39个,占30.2%;治疗性指标44个,占34.1%;随访性指标21个,占16.3%;健康教育性指标14个,占10.9%。
2、进行了实证研究。选用了某医院干部保健病房2008.1-2009.6之间的出院病历,选取ICD-10及ICD-9中第一诊断为前列腺增生、慢性阻塞性肺气肿、心衰、脑梗死、急性冠脉综合征、白内障、社区获得性肺炎的病历共132份,利用课题组构建的干部保健对象医疗质量评价指标体系进行实证研究。
132名保健对象得到了80.9%的被推荐服务(即各指标的平均执行率为80.9%),其中治疗相关指标的执行率最高,为90.9%,诊断相关指标的执行率最低,为70.4%,疾病筛查及预防指标的执行率为89.7%,随访指标的执行率为80.1%,健康教育指标的执行率为77.4%。对于各疾病状况及老年综合征而言,执行率最高的为疾病预防与筛选,达到了100%,最低的为跌倒和运动障碍,为10%。
实证研究结果表明,某医院干部保健对象整体上得到了很好的保健医疗质量,但依然有一定的提升空间,特别是执行率低于50%的指标,是我们目前需要关注和加强的领域,例如在抑郁、跌倒和运动障碍的筛查等方面。
研究的创新点:
本研究在大量阅读分析了国内外质量评价、特殊人群医疗质量评价的文献基础上,结合我国干部保健工作的特点,探索性地进行了以下工作:
1、首次对干部保健对象的医疗质量进行综合性评价研究;
2、首次全部以过程指标作为质量评价的指标体系,进行医疗质量评价的探索;
3、首次对某医院保健对象的典型病例进行了综合查阅,进行了质量评价的实证研究。
本研究不足:
本研究主要存在以下局限性:
1、样本量偏小。
2、实证研究选取的研究对象来源于单个保健中心的住院病人,因而结果的代表性受限。
3、指标体系的内容可以采用部分结果指标。
针对上述不足,拟在今后继续开展的研究包括:
1、针对此次实证研究的数据,进行专家咨询,对指标进一步修改完善;
2、针对干部保健对象主要为老人的特点,评价指标中涵盖的内容可以更加丰富。例如,多学科综合管理、重症综合救治以及恶性肿瘤的规范救治等以及患者满意度、生存质量等结果指标,使其更加合理。
3、可以根据评价的人群细化指标体系。本研究的主要人群为某医院住院患者,在后续的研究中,应针对评价人群将指标进一步细化:评价住院患者的指标、评价干休所居住患者的指标等。
4、与相关部门合作,在医生工作站和护士工作站建立质量评价指标的提醒系统,以督促、提醒医务人员按照诊疗规范进行操作。
Background:
The state attach great importance to health care for senior officials and invest a great deal of energy and financial resource to develop health care system. What about the health care quality for senior officials and how to assess the quality, is the most important things that we want to know. The quality of care among senior officials has not been extensively investigated. This study want to create a set of indicators and assess the quality of health care for senior officials. This research is the project subject to special research projects sponsored by Central Health Committee, that is, The Study on the Integrative System of Health Assessment, Early Screening and Comprehensive Intervention.
Objective:
(1) To develop a set of evidence-based indicators to assess the quality of health care delivered to senior cadres.
(2) To measure the quality of medical care provided to hospitalized elder cadres by evaluating the process of care using the developed indicators.
Methods:
A modified version of the RAND/UCLA appropriateness method was used to develop indicators.
1、To identify important medical conditions that affect elder cadres and for which effective menthods of prevention or management exist.A list of 21 conditions common among elder cadres was proposed on the basis of their(1)prevalence,(2)impact on health and quality of life,(3)effectiveness of interventions in improving mortality and quality of life,(4)feasibility of obtaining the data. A panel of 15 experts in geriatric care discussed and the ranked the 21 conditions on the basis of the same three criteria.We then selected 12 conditions.
2、For each coditions,a contents expert created potential quality indicators (QIs) based on systematic reviews and guideline.A multidisciplinary panels of clinical experts participated in two rounds of anonymous ratings and a face-to-face group discussion to evaluate weather the QIs were valid measures of quality of health care using a process that is an explicit combination of scientific evidence and professional consensus.
3、And 132 hospitalized elder cadres aged 60 or older admitted to a general hospital from Jan 1,2008 to June 30 ,2009 were studied. Using the set of indicators, the health care quality delivered to the senior officials were assessed.
Results:
(1) A list of 21 conditions common among elder cadre were proposed to a panel of 15 experts in geriatric care.The 12 conditions were selected as targets for quality assessment,including(in rank order):hypertension, diabetes mellitus, acute coronary syndrome,stroke, chronic obstructive pulmonary disease, benign prostatic hyperplasia, community-acquired pneumonia,heart failure,preventive service,depression,vision impairment,falls and mobility disorders.
(2) 171 quality indicators on health care for cadres were assessed by the panel. 129 quality indicators (QIs),covering 12 conditons,were selected.These quality indicators coverd all five domains of care:screening and prevention(8.5% of QIs),diagnosis(30.2% of QIs),treatment(34.1% of QIs),follow up (16.3% of QIs)and health education(10.9% of QIs).
(3) Participants received 80.9 percent of recommended care.Ninty percent of Qls focused on treatment were passed. This rate was higher than the adherence to QIs for care processes aimed at follow-up (80.1%), diagnosis (70.4%),health education (77.4%) or prevcntion (89.7%) . The percentage of indicated care received by participants was highest for preventive and screening(100%), lowest for falls and mobility(10%).
Discussion:
The study focused on developing indicators and measuring of health care quality for elder cadre.The results indicated the cadres received good medical service.But there were some deficiencies for conditions such as falls,depression.
Our study has some strengths, including the methods used to construct the QIs, which involved systematic reviews,group judgment of a multidisciplinary expert panel. We also supplemented medical record information with data from patient telephone-interviews to better capture care that might nor have been recorded and ro account for patient preferences. Third, we assessed care across a very broad range of conditions that included indicators assessing prevention, treatment, diagnosis, and follow-up. Our study both calls attention to these deficiencies and provides a comprehensive method to assess the effectiveness of interventions to improve medical care.
引文
1.总后勤部。《军队医疗保健工作规定》。2007年。
2.白书忠.认清形势明确任务,努力开创干部保健工作新局面.解放军保健杂志,2000,2(2).
3.关于印发《关于进一步加强军队高中级干部医疗保健和安全工作的意见》。2000年
4.张新军,黄晓丽,王业钊,等.循证医学实践与干部医疗保健工作.华西医学,2003,18(2):196-197.
5.王捍峰.在保健工作中学习、掌握和实践循证医学——在卫生部保健局循证医学培训班的讲话。中国临床保健杂志,2005,8(4):289.
6. Sakett D L,Richardson W S,Rosenburg W,et al.Evidence-Base Medicine:how to practice and teach EBM[M] .2nd ed. Philadelphia: Churchill Livingstone, 2000:385.
7.王赤军,刘海波。“两高期"老干部健康特点和医疗保障做法与建议。中华保健医学杂志,2008,10(2):140-141。
8.覃静,张锐。老干部医疗保健工作的特点与对策。人民军医,2007,50(12):775.
9.王玉平,秦银河。论如何做好军队在职高级干部医疗保健工作。解放军保健医学杂志,2005,7(3):173-174.
10.印发《军队疗养工作管理规定》。2002年
11.印发《军队干休所卫生工作管理规定》。2002年
12. Shekelle P. The Appropriateness Method. Med Decis Making,2004,24(4):228-231.
13.汪唯,杨秀群,匡莉.卫生服务适宜性测量方法-RAND专家小组评价法.国外医学卫生经济分册,2007,24(3):136-137.
14. Campbell S M, Braspenning J, Hutchinson A, et al.Research methods used in developing and applying quality indicators in primary care. BMJ. 2003,326(4): 816–819.
15.曾光。现代流行病学方法与应用。北京:北京医科大学协和医科大学联合出版社,1996.
16.李俊勇,刘民,周丽。医学科研项目全程评价指标体系的建立。中华医学科研管理杂志,2005,18(1):33-36.
17.刘丹红,徐勇勇,甑家欢等。医疗质量及其评价指标概述。中国卫生质量管理,2009,16(2):57-61
18.朱士俊主编。医院管理学。北京:人民卫生出版社,2003:9-10
19.李岩编译。医疗质量评估与检测。北京:北京大学出版社,2005:14
20. Roemer MI, Montoya C. Quality assessment and assurance in primary healthcare. WHO Offset Publication, World Health Organization. Geneva, Switzerland. 1998.
21. Abby Ghobadian, et al. Service quality concepts models. International Journal of Quality&Reliability Management, 1994,11(9):43-66.
22. U. S. Department of Health and Human Services. 2007 National Healthcare Disparities Report . Quality of Health Care,2008 :31-32.
23.曹荣桂主编。医院管理学。人民卫生出版社,2003:259
24.王静,张亮。卫生服务质量评价与研究。中国卫生事业管理,2003,(9):552-553
25.任真年。现代医院医疗质量管理。北京:人民军医出版社。2005:418
26.李曙光,尹爱田,曹艳民.医疗服务质量评价解析.中华医院管理,2004,20(11):661-663
27.尹爱田,李曙光,张兴旭。对医疗质量评价指标体系的评析。中华医院管理,2004,
21(3):169-172.
28.于亚滨,马谢民。医疗质量的科学评价及其进展。中国病案,2005,6(5):17-19
29.孟普。医疗不良事件已成为世界性问题.医院管理论坛,2007,11:28-30
30.杨帆,秦银河,董军.国外医疗质量评价的实施与思考.中国医院,2005,9(1):73-75
31.阎小妍,孟虹,汤明新。美国医院医疗质量评价体系及评价方法。中华医院管理,2006,22(4):285-288
32. www.ahrq.gov.
33.马谢民。国际医疗质量指标体系及其特点。中国医院管理,2007,27(11):22-24
34. http://www.rand.org/about
35. McGlynn EA, Asch SM, Adams J,et al. The Quality of Health Care Delivered to Adults in the United States. NEJM,2003,348(7):2635-2645.
36. About the Danish National Indicator Project .WWW.NIP.DK
37. Determining the Potential to Improve the Quality of Care in Australian Health Care organisations: Results from the ACHS Clinical Indicators Data, 1998 -2002 , The Australian Council on Healthcare Standards
38.杨辉,Shane Thomas,David Legge,等。澳大利亚医疗服务质量管理的理念和做法。中国卫生质量管理,2006,13(4):4-7
39.陈虎,焦亚辉,舒婷。澳大利亚的临床服务质量指标体系。中国医院,2009,13(4):18-20
40.王冬,张罗漫。医疗质量评价指标的回顾与分析。中华医院管理杂志,2001,17(2):90-92
41.马谢民。我国评价医疗质量指标中存在的主要问题。中国医院,2008,12(2):32-34
42.卫生部医政司,中国医院协会。单病种质量管理手册(1.0版)。科学技术文献出版社,2007.
43.医疗质量评价管理。国家卫生部。http://www.moh.gov.cn/publicfiles/business/ htmlfiles/mohyzs/s2909/
44.赵明刚,梁铭会,俞汝龙。CHQIS医疗质量评价指标体系的设计与实现。中国医院,2009,13(4):2-4
45.彭迎春,王园,常文虎,等。全科医疗质量评价指标体系的研究。中国全科医学,2004,7(3):158-160.
46.武秀昆。院前急救医疗服务质量调查方案设计与指标意义分析。中华医院管理杂志,2008,24(8):538-541.
47. Kavanagh PL, Adams WG,Wang CJ.Quality indicators and quality assessment in child health. Arch Dis Child 2009;94:458–463
48. Improving the Health and Health Care of Older Americans:A Report of the AHRQ Task Force on Aging.www.ahrq.gov.
49. Shekelle PG, MacLean CH, Morton SC, W et al. Assessing care of vulnerable elders: methods for developing quality indicators. Ann Intern Med,2001;135:647-52
50. Wenger NS, Shekelle PG.Assessing care of vulnerable elders: ACOVE project overview.Ann Intern Med. 2001;135:642-7.
51. Wenger NS, Roth CP, Shekelle P; ACOVE Investigators. Introduction to the assessing care of vulnerable elders-3 quality indicator measurement set.J Am Geriatr Soc. 2007 ;55 Suppl 2:S247-52.
52. Seth C.Improving health care for older persons. Ann Intern Med 2003;139:421-424
53. Improving the quality of health care for older adults.www.rand.org.
54. Sloss EM, Solomon DH, Shekelle PG, et al. Selecting target conditions for quality ofcare improvement in vulnerable older adults. J Am Geriatr Soc. 2000;48:363-9
55. Assessing care of vulnerable elders-3 quality indicators.J Am Geriatr Soc. 2007 Oct;55 Suppl 2:S464-87.
56. Arora VM, Plein C, Chen S,et al. Relationship between quality of care and functional decline in hospitalized vulnerable elders. Med Care. 2009 Aug;47(8):895-901.
57. Wenger NS, Shekelle P, eds. Measuring medical care provided to vulnerable elders: The Assessing Care of Vulnerable Elders-3 (ACOVE-3) quality indicators. J Am Geriatr Soc 2007;55(S2):S247-487
58. Steel N, Melzer D, Shekelle PG,et al. Developing quality indicators for older adults: transfer from the USA to the Uk is feasible. Qual Saf Health Care 2004;13:260-4.
59. Steel N,Maisey S, Breeze E,et al.Self reported receipt of care consistent with 32 quality indicators: national population survey of adults aged 50 or more in England.BMJ 2008;13(8) 13;337-345
60. Vander PE, Depla MF, Shekelle P,et al. Developing quality indicators for general practice care for vulnerable elders transfer from US to The Netherlands. Qual Saf Health Care. 2008 Aug;17(4):291-5
61. Lilford R J, Brown C A, Nichol J.Use of process measures to monitor the quality of clinical practice.BMJ, 2007,335(9):648-650.
62.张建主编。中国老年卫生服务指南。北京:华夏出版社,2004:9
63.朱宪。北京地区离退休高级知识分子健康状况调查和分析。中国全科医学,2004,7(9):639-641.
64.吕世亭。综合性医院老年住院病人疾病谱分析。浙江医学,2001,23(11)
65.石梅初,杨海伟,赵承初。1119名军队高级干部医疗保健研究。西南军医,2009,11(1):58-59.
66.黄建英,钟长霞,梁丽。14590例60岁及以上老年住院病人统计分析。医学信息,2008;21(7):1028-2030.
67.β-Blocker Heart Attack Trial Research Group .A randomized trial of propranolol in patients with acute myocardial infarction.II.Morbidity results.JAMA ,1983, 250:2814–2819.
68. First International Study of Infarct Survival Collaborative Group.Randomised trial of intravenous atenolol among 16 027 cases of suspected acute myocardialinfarction.Lancet,1986;2:57–66.
69. Hjalmarson A,Elmfeldt D,Herlitz J et al.Effect on mortality of metoprolol in acute myocardial infarction.A double-blind randomised trial.Lancet,1981;2:823–827.
70.席建伟,Corrine MH,蔡尚郎。美国心脏康复的概况。心血管康复医学杂志,2006,15(S):67-69.
71. Karol W,Constance H.F,Matthew B. Quality Indicators for the Care of Ischemic Heart Disease in Vulnerable Elders. CCC
72.何成奇,谢薇,杨霖等。老年患者的心脏康复。中国康复,2008,23(2):131-132
73. Lavie CJ,Milani RV.Disparate effects of improving aerobic exercise capacity and quality of life after cardiac rehabilitation in young and elderly coronary patients.J Cardiopulm Rehabil,2000;20:235–240.
74. Jolliffe JA,Rees K,Taylor RS et al.Exercise-based rehabilitation for coronary heart disease.Cochrane Database Syst Rev,2001;(1):CD001800.
75. Wenger NK,Froelicher ES,Smith LK et al.Cardiac rehabilitation as secondary prevention.Agency for Health Care Policy and Research and National Heart,Lung,and Blood Institute.Clin Pract Guidel Quick Ref Guide Clin 1995;17:1–23.
76.杨祖福。心脏康复及其在我国的发展。中国康复理论与实践,2008,14(4):301-302.
77.蒋永红.老年冠心病患者抑郁症状的调查.现代中西医结合杂志, 2008, 17 (4): 45-656.
78. Glassman AH, Shapiro PA. Depression and course of coronary artery disease. Am J Psychiatry, 1998, 155: 4.
79. coronary heart disease events: the Italian longitudinal study on aging . Gerontol A Biol Sci Med, 2005, 60: 85-92.
80. www.premierinc.com/p4p/hqi
81.中国急性冠状动脉综合征多中心临床研究协作组。中国多省市急性冠脉综合征住院患者治疗现状与指南差距分析。中华心血管病杂志,2005,33(9):789-792.
82.卫生部医政司医疗质量评价与管理处。2007年度北京地区十六所三级甲等医院检查:质量与安全评价报告。
83. Yufang Bi,Runlin Gao,Anushka P. Evidence-based medication use among Chinese patients with acute coronary syndromes at the time of hospital discharge and 1 year after hospitalization:Results from the Clinical Pathways for Acute Coronary Syndromesin China(CPACS)study. American Heart Journal,2009,157(3):509-516.March 2009
84.彭小岭,曾宪容。脑卒中后抑郁及干预的研究进展。实用医院临床杂志,2009,6(6):129-131.
85. Hackett ML,Yapa C,Parag V et al.Frequency of depression after stroke:A systematic review of observational studies.Stroke,2005;36:1330–1340.
86. Hackett ML,Anderson CS,House AO.Management of depression after stroke:A systematic review of pharmacological therapies.Stroke 2005;36:1098–1103
87. Antiplatelet Trialists’Collaboration. Collaborative meta-analysis of randomized trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients[J].BMJ,2002,324:71-86.
88. Holloway RG,Bebesch C,Rush SR. Stroke prevention:narrowing the evidence-practice gap.Neurology,2000,54:1899-1906.
89. www.dhmc.org/qualityreports/
90.吴敌,王伊龙,马锐华等。缺血性脑卒中患者二级预防中抗血栓药物使用现况调查。中华老年心脑血管病杂志,2006,8(5):325-328.
91.王伊龙,张振伟,王拥军等。2008年北京地区脑梗死住院患者医疗服务质量评价研究。中国卫生质量管理,2010,17(1):12-15
92. Eric K. Quality Indicators for the Care of Chronic Obstructive Pulmonar Disease in Vulnerable Elders. J Am Geriatr Soc.2007,55(NS2):270-276.
93.中华医学会。临床诊疗指南(呼吸病学分册)。人民卫生出版社,第一版,2009年。
94.张祥华。中国版良性前列腺增生临床诊治指南的制定。临床药物治疗杂志,2007,5(2):1-4
95.中华医学会呼吸病学分会。社区获得性肺炎诊断和治疗指南。中华结核和呼吸病学杂志,2006,29(10):651-655.
96. Ochoa-GondarO,Vila Crcoles A , de Diego C , et al . The burden of community—acquired pneumonia in the elderly:the Spanish EVAN-65 study.BMC Public Health,2008,8:222.
97. Jackson ML,Neuzil KM,Thompson W,et al.The burden of community-acquried pnemuonia in seniors:results of a population-based study.Clin Infect Dis,2004,39(11):1642-1650
98. Marston BJ,Plouffe JF,File TM Jr,et a1.Incidence of community—acquiredpneumonia requiring hospitalization:results of a population-based active surveillance study in Ohio.The community—based pneumonia incidence study group.Arch Intern M ed,1997,157:1709一1718.
99. Stafford RS,Radley DC.The underutilization of cardiac medications of proven benefit,1990-2002[J].J Am Coll Cardio,2003,41(1):56-61.
100.上海市稳定性心力衰竭调查协作组.上海市稳定性心力衰竭患者药物治疗现状调查[J].中华心血管病杂志,2001,29(11):644-648.
101.傅华等。预防医学(第五版)。北京:人民卫生出版社,2008
102. Nallini G,Constance HF. Quality Indicators for Screening and Prevention in Vulnerable Elders. J Am Geriatr Soc.2007,55(NS2):417-423.
103.沈渔邨。精神病学(第二版)。北京:人民卫生出版社,1994
104.王冬,张罗漫.医疗质量评价指标的回顾与分析.中华医院管理杂志,2001,17:90-92.
105. Wenger NS.Do We Want to Measure the Quality of Care for Vulnerable Older People? http://www-cpr.maxwell.syr.edu/pbriefs/pb38.pdf
106. Muir G,唐金陵.循证医疗卫生决策[M].北京:北京大学医学出版社,2004:1-2.
107.王家良.循证医学[M].北京:人民卫生出版社,2001:197.
108. Eric K. Quality Indicators for the Care of Chronic Obstructive Pulmonary Disease in Vulnerable Elders. J Am Geriatr Soc.2007,55(NS2):270-276.
109. Littmann V, Lauterbach KW. An evidence-based evaluation of quality and efficiency indicators. Qual Manag Health Care ,2002,10(4):41-52.
110. BALLARD DJ. Indicators to improve clinical quality across an integrated health care system. International Journal for Quality in Health Care, 2003; 15(Supplement 1):13–23.
111. Pitches D, Mohammed MA, Lilford RJ. What is the evidence that hospitals with higher risk-adjusted mortality rates provide poorer care? A systematic review of the literature. BMC Health Serv Res ,2007;7:91-95
112. Richard J L,Celia A B,Nicholl J. Use of process measures to monitor the quality of clinical practice. BMJ , 2007;335:648-650 (29 September).
113. McGlynn EA, Asch SM, Adams J,et al. The Quality of Health Care Delivered to Adults in the United States. NEJM,2003,348(7):2635-2645.
114. Wenger NS,Solomon DH,Roth CP. The Quality of Medical Care Provided toVulnerable Community-Dwelling Older Patients. Ann Intern Med. 2003;139:740-747.
115. Steel N,Maisey S, Breeze E,et al.Self reported receipt of care consistent with 32 quality indicators: national population survey of adults aged 50 or more in England.BMJ 2008;13(8) 13;337-345.
116.刘宏军,孟琛,汤哲。北京市老年人抑郁症状的调查。中国心理卫生杂志,2004,18(11):794-795.
117.杨雪莹,李永成,王淑惠等。天津市老年人抑郁调查及其影响因素分析。中国老年学杂志,2007,27(10):1921-1923.
118.陈明远,张艳。离退休老年人抑郁状况及其相关因素分析。护理研究,2008,22(12):3186-3187.
119.杨晓秋,任素琴,钱远宇等。部队离退休老年人抑郁情绪的相关因素调查及干预措施。现代护理,2005,11(6):429-431.
120.王鲁宁。重视老年抑郁症的诊断及治疗。中华内科杂志,1999,38(1):68
121.黄颐,孙学礼,付华等。心血管疾病中的心理问题。国外医学精神疾病分册,2004,31(1):10-12.
122. Frasure SN,Lespersure F,Jalajic M. Depression and 18-month prognosis After MyocardialInfarction . Circulation,1995,91(4):999-1005.
123. Nakajima GA,Wenger NS. Quality Indicators for the Care of Depression in Vulnerable Elders. J Am Geriatr Soc.2007,55(NS2):302-311.
124. Brady R,Chester FR,Pierce LL,et al.Geriatric falls:Prevention strategies for the staff.J Gerontol Nurs,1993,19(3):26-32.
125. Rubenstein LZ,Powers CM, MacLean CH. Quality Indicators for the Management and Prevention of Falls and Mobility Problems in Vulnerable Elders. Ann Intern Med.2001;135:686-693.
126. Tromp AM,Pluijm SM,Smit JH et al.Fall-risk screening test:A prospective study on predictors for falls in community-dwelling elderly.J Clin Epidemiol ,2001;54:837–844.
127. Chu LW,Chi I,Chiu AY.Incidence and predictors of falls in the Chinese elderly.Ann Acad Med Singapore 2005;34:60–72.
128. Tinetti ME,Speechley M,Ginter SF.Risk factors for falls among elderly persons living in the community.N Engl J Med 1988;319:1701–1707.
129. Blake AJ,Mor gan K,Bendall MJ et al.Falls by elderly people at home:Prevalence and associated factors.Age Ageing 1988;17:365–472.
130. O’Loughlin JL,Robitaille Y,Boivin JF et al.Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly.Am J Epidemiol 1993;137:342–354
131. 1 Chang JT,Ganz DA. Quality Indicators for Falls and Mobility Problems in Vulnerable Elders. J Am Geriatr Soc.2007,55(NS2):327-334.
132. Constance HF, Lim YW, Soeren M, et al.Systematic review: the evidence that publishing patient care performance data improves quality of care. Ann Intern Med 2008;148:111-123
133. Lombarts MJ, RuppI , Vallejo P, et al. Application of quality improvement strategies in 389 European hospitals: results of the MARQuIS project. Qual Saf Health Care, 2009 18: 28-37.
134.汪唯,杨秀群,匡莉.卫生服务适宜性测量方法-RAND专家小组评价法.卫生经济研究。2007,7,10-11.
135.李敏,李庆云,罗文侗等。上海市社区获得性肺炎诊疗现状调查分析。上海医学,2003,26(12):871-874
136. Davies H.Measuring and Reporting the quality of health care.www. nhshealthquality.org.
1. Roemer MI, Montoya C. Quality assessment and assurance in primary healthcare. WHO Offset Publication, World Health Organization. Geneva, Switzerland. 1998.
2. Abby Ghobadian, et al. Service quality concepts models. International Journal of Quality&Reliability Management, 1994,11(9):43-66.
3.曹荣桂主编。医院管理学。人民卫生出版社,2003:259
4. 4李曙光,尹爱田,曹艳民.医疗服务质量评价解析.中华医院管理,2004,20(11):661-663
5. Kavanagh PL, Adams WG,Wang CJ.Quality indicators and quality assessment in child health. Arch Dis Child 2009;94:458–463
6. Improving the Health and Health Care of Older Americans:A Report of the AHRQ Task Force on Aging.www.ahrq.gov.
7. Shekelle PG, MacLean CH, Morton SC, W et al. Assessing care of vulnerable elders: methods for developing quality indicators. Ann Intern Med,2001;135:647-52
8. Wenger NS, Shekelle PG.Assessing care of vulnerable elders: ACOVE project overview.Ann Intern Med. 2001;135:642-7.
9. Wenger NS, Roth CP, Shekelle P; ACOVE Investigators. Introduction to the assessingcare of vulnerable elders-3 quality indicator measurement set.J Am Geriatr Soc. 2007 ;55 Suppl 2:S247-52.
10. Improving the quality of health care for older adults.www.rand.org.
11. Seth C.Improving health care for older persons. Ann Intern Med 2003;139:421-424
12. Saliba D, Elliott M, Rubenstein LZ, Solomon DH, et al. The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc. 2001;49:1691-9.
13. Wenger NS, Solomon DH, Roth CP, et al.The quality of medical care provided to vulnerable community-dwelling older patients. Ann Intern Med. 2003;139:740-7
14. Fried LP.Establishing benchmarks for quality care for an aging population:caring for Vulnerable Older Adults . Ann Intern Med. 2003;139:784-6
15. Min LC, Elliott MN, Wenger NS et al. Higher vulnerable elders survey scores predict death and functional decline in vulnerable older people. J Am Geriatr Soc; 2006;54:507-511.
16. Min LC, Yoon W, Mariano J et al. The vulnerable elders-13 survey predicts 5-year functional decline and mortality outcomes in older ambulatory care patients.J Am Geriatr Soc. 2009 Nov;57(11):2070-6.
17. ACOVE Investigators. ACOVE quality indicators. Ann Intern Med. 2001;135:653-67
18. Assessing care of vulnerable elders-3 quality indicators.J Am Geriatr Soc. 2007 Oct;55 Suppl 2:S464-87.
19. Sloss EM, Solomon DH, Shekelle PG, et al. Selecting target conditions for quality of care improvement in vulnerable older adults. J Am Geriatr Soc. 2000;48:363-9
20. Wenger NS, Shekelle P, eds. Measuring medical care provided to vulnerable elders: The Assessing Care of Vulnerable Elders-3 (ACOVE-3) quality indicators. J Am Geriatr Soc 2007;55(S2):S247-487
21. Arora VM, Plein C, Chen S,et al. Relationship between quality of care and functional decline in hospitalized vulnerable elders. Med Care. 2009 Aug;47(8):895-901.
22. John E. Caring for the Vulnerable Elderly: Are Available Quality Indicators Appropriate? Journal of the American Medical Directors Association 2008;9(1): 1-3
23. Steel N, Melzer D, Shekelle PG,et al. Developing quality indicators for older adults: transfer from the USA to the Uk is feasible. Qual Saf Health Care 2004;13:260-4.
24. 24: Steel N,Maisey S, Breeze E,et al.Self reported receipt of care consistent with 32 quality indicators: national population survey of adults aged 50 or more in England.BMJ 2008;13(8) 13;337-345
25. Vander PE, Depla MF, Shekelle P,et al. Developing quality indicators for general practice care for vulnerable elders transfer from US to The Netherlands. Qual Saf Health Care. 2008 Aug;17(4):291-5
26. Constance HF, Lim YW, Soeren M, et al.Systematic review: the evidence that publishing patient care performance data improves quality of care. Ann Intern Med 2008;148:111-123