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Article(id=1241342460698349886, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1241342451043061769, articleNumber=null, orderNo=null, doi=10.20043/j.cnki.MPM.202310236, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1697472000000, receivedDateStr=2023-10-17, revisedDate=null, revisedDateStr=null, acceptedDate=null, acceptedDateStr=null, onlineDate=1773888705658, onlineDateStr=2026-03-19, pubDate=1708790400000, pubDateStr=2024-02-25, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1773888705658, onlineIssueDateStr=2026-03-19, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1773888705658, creator=13701087609, updateTime=1773888705658, updator=13701087609, issue=Issue{id=1241342451043061769, tenantId=1146029695717560320, journalId=1227665162245664772, year='2024', volume='51', issue='4', pageStart='577', pageEnd='768', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1773888703356, creator=13701087609, updateTime=1773893026321, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1241360582939562716, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1241342451043061769, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1241360582939562717, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1241342451043061769, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=674, endPage=679, ext={EN=ArticleExt(id=1241342461134557537, articleId=1241342460698349886, tenantId=1146029695717560320, journalId=1227665162245664772, language=EN, title=Study on the single-disease settlement cost and influencing factors of age-related cataract surgery patients under the centralized volume-based procurement policy of intraocular lens, columnId=1228016567846367388, journalTitle=Modern Preventive Medicine, columnName=Health Policy and Management, runingTitle=null, highlight=null, articleAbstract=
Objective

To study the single-disease settlement cost and its influencing factors for age-related cataract surgery patients under the centralized volume-based procurement policy of intraocular lens, and to provide theoretical suggestions and data support for optimizing the cost structure, controlling the growth of medical costs, and improving the quota payment policy of intraocular lens materials.

Methods

The medical records and single-disease payment information of 215 age-related cataract patients admitted to the Department of Ophthalmology of a provincial tertiary public general hospital in Guangzhou from June 1, 2021 to April 30, 2022 were collected. Descriptive analysis, new grey correlation analysis and multiple linear regression model were used to analyze the composition and influencing factors of single-disease settlement expenses and the burden of intraocular lens materials.

Results

The treatment cost, intraocular lens cost and diagnosis cost were the main types of hospitalization expenses for age-related cataract surgery patients (accounting for 52.12%, 19.79% and 13.56% respectively, accounting for 85.47% in total). At the same time, it was also the main type of expense affecting the average hospitalization expense per time (the correlation coefficients were 1.000, 0.751, 0.717). Multiple linear regression analysis showed that the length of hospital stay, anesthesia type (local anesthesia as the reference, general anesthesia β=3 513.340) and intraocular lens type (soft spherical three-piece monofocal non-astigmatism type as the reference, soft aspheric one-piece monofocal astigmatism type β=2 590.090; soft aspheric one-piece continuous visual field non-astigmatism type β=10 496.020, soft aspheric one-piece trifocal non-astigmatism type β=21 889.810) were the influencing factors of hospitalization expenses (P<0.001). Under the medical insurance limit payment of intraocular lens material fee, the proportion of the highest burden of patients is low when the selected intraocular lens unit price is less than the maximum limit standard (1 800 yuan), and the proportion of the highest burden of patients increases with the increase of the price of intraocular lens when the selected intraocular lens unit price is more than the maximum limit standard (1 800 yuan).

Conclusion

The structure of hospitalization expenses for age-related cataract surgery becomes more reasonable under the centralized volume-based procurement policy of intraocular lens, and the labor value of medical staff is realized. However, more attention should be paid to the changes of intraocular lens costs and diagnostic fees in the future. Shortening the length of hospital stay, reasonable selection of anesthesia methods, reasonable selection of different types of intraocular lens and reducing the price of intraocular lens can effectively reduce the hospitalization cost of age-related cataract surgery patients. Appropriately raising the fee limit of intraocular lens materials according to the affordability of local medical insurance fund is helpful to reduce the cost burden of surgical patients.

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目的

对人工晶体集中带量采购政策下的老年性白内障手术患者单病种结算费用及影响因素进行研究，为优化费用结构和控制医疗费用增长以及完善人工晶体材料限额付费政策提供相应的理论建议和数据支撑。

方法

收集广州某省属三级甲等公立综合医院眼科2021年6月1日至2022年4月30日收治的215例老年性白内障手术患者的病案资料及单病种结算费用信息，采用描述性分析、新灰色关联分析和建立多因素线性回归模型分析单病种结算费用的构成、影响因素以及人工晶体材料费负担情况。

结果

治疗费、人工晶体费和诊断费是构成老年性白内障手术患者住院费用的主要费用类型（占比分别为52.12%、19.79%、13.56%，合计占85.47%），同时也是影响次均住院费用的主要费用类型（关联度分别为1.000、0.751、0.717）；多因素线性回归分析显示，住院天数、麻醉方式（以局部麻醉为参照，全身麻醉β=3 513.340）和人工晶体类型（以软性球面三片式单焦点非散光型为参照，软性非球面一片式单焦点散光型β=2 590.090，软性非球面一片式连续视程非散光型β=10 496.020，软性非球面一片式三焦点非散光型β=21 889.810）是住院费用的影响因素（P<0.001）；人工晶体材料费医保限额支付下，所选人工晶体单价≤最高限额标准（1 800元）时患者最高负担比例较低，所选人工晶体单价>最高限额标准（1 800元）时患者最高负担比例随着人工晶体价格的增加而增加。

结论

人工晶体集中带量采购政策下老年性白内障手术患者住院费用结构趋于合理，医务人员劳务价值得以体现，但后续应重点关注人工晶体费和诊断费的变化。缩短住院天数、合理选择麻醉方式、合理选择不同类型的人工晶体以及降低人工晶体价格可有效降低老年性白内障手术患者住院费用。根据属地医保基金承受能力适当上调人工晶体材料费限额标准有助于减轻手术患者费用负担。

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姚卫光，E-mail：
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彭勇华(1992—)，男，硕士在读，研究方向：社会医学与卫生事业管理

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Composition analysis of average hospitalization expenses[yuan(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
费用类型次均费用（构成比）不同医保类型次均费用（构成比）
居民医保（n=43）职工医保（n=172）
住院费用7 778.45（100.00）7 531.64（100.00）7 840.15（100.00）
药品费418.10（5.38）422.72（5.61）416.95（5.32）
综合医疗服务费256.01（3.29）251.92（3.34）257.03（3.28）
诊断费1 054.8（13.56）1 045.60（13.88）1 057.11（13.48）
治疗费4 054.42（52.12）4 043.41（53.69）4 057.18（51.75）
康复费16.65（0.21）16.28（0.22）16.74（0.21）
人工晶体费1 539.33（19.79）1 300.00（17.26）1 599.16（20.40）
其他医用材料费439.13（5.65）451.71（6.00）435.98（5.56）
), ArticleFig(id=1241342467992244938, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241342460698349886, language=CN, label=表1, caption=

次均住院费用构成分析[元（%）]

, figureFileSmall=null, figureFileBig=null, tableContent=
费用类型次均费用（构成比）不同医保类型次均费用（构成比）
居民医保（n=43）职工医保（n=172）
住院费用7 778.45（100.00）7 531.64（100.00）7 840.15（100.00）
药品费418.10（5.38）422.72（5.61）416.95（5.32）
综合医疗服务费256.01（3.29）251.92（3.34）257.03（3.28）
诊断费1 054.8（13.56）1 045.60（13.88）1 057.11（13.48）
治疗费4 054.42（52.12）4 043.41（53.69）4 057.18（51.75）
康复费16.65（0.21）16.28（0.22）16.74（0.21）
人工晶体费1 539.33（19.79）1 300.00（17.26）1 599.16（20.40）
其他医用材料费439.13（5.65）451.71（6.00）435.98（5.56）
), ArticleFig(id=1241342468382315221, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241342460698349886, language=EN, label=Table 2, caption=

Correlation degree and correlation sequence of each time average cost in age-related cataract surgery patients

, figureFileSmall=null, figureFileBig=null, tableContent=
费用类型关联度关联序不同医保类型的比较
居民医保（n=43）职工医保（n=172）
关联度关联序关联度关联序
药品费0.67750.66750.6795
综合医疗服务费0.66760.65660.6694
诊断费0.71730.70730.7193
治疗费1.00011.00011.0001
康复费0.65370.64370.6567
人工晶体费0.75120.72520.7582
其他医用材料费0.67840.66940.6636
), ArticleFig(id=1241342468545893089, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241342460698349886, language=CN, label=表2, caption=

老年性白内障手术患者各项次均费用关联度及关联序

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费用类型关联度关联序不同医保类型的比较
居民医保（n=43）职工医保（n=172）
关联度关联序关联度关联序
药品费0.67750.66750.6795
综合医疗服务费0.66760.65660.6694
诊断费0.71730.70730.7193
治疗费1.00011.00011.0001
康复费0.65370.64370.6567
人工晶体费0.75120.72520.7582
其他医用材料费0.67840.66940.6636
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Variable assignment table

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变量名称变量代码哑变量赋值
住院费用Y实际值
性别X10=男；1=女
年龄X2实际值
医保类型X30=居民医保；1=职工医保
其他诊断疾病数量X4实际值
麻醉方式X50=局部麻醉；1=全身麻醉
人工晶体类型X6以“软性球面三片式单焦点非散光型”为参照组
X6_1软性非球面一片式单焦点非散光型=1,else=0
X6_2软性非球面一片式单焦点散光型=1,else=0
X6_3软性非球面一片式连续视程非散光型=1,else=0
X6_4软性非球面一片式三焦点非散光型=1,else=0
住院天数X7实际值
是否临床路径管理X80=否；1=是
), ArticleFig(id=1241342468784968435, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241342460698349886, language=CN, label=表3, caption=

变量赋值表

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变量名称变量代码哑变量赋值
住院费用Y实际值
性别X10=男；1=女
年龄X2实际值
医保类型X30=居民医保；1=职工医保
其他诊断疾病数量X4实际值
麻醉方式X50=局部麻醉；1=全身麻醉
人工晶体类型X6以“软性球面三片式单焦点非散光型”为参照组
X6_1软性非球面一片式单焦点非散光型=1,else=0
X6_2软性非球面一片式单焦点散光型=1,else=0
X6_3软性非球面一片式连续视程非散光型=1,else=0
X6_4软性非球面一片式三焦点非散光型=1,else=0
住院天数X7实际值
是否临床路径管理X80=否；1=是
), ArticleFig(id=1241342468881437437, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241342460698349886, language=EN, label=Table 4, caption=

Results of multiple linear regression analysis of hospitalization costs

, figureFileSmall=null, figureFileBig=null, tableContent=
变量名称非标准化偏回归系数标准化偏回归系数βt值P值
β标准误
常数6 710.562147.755-45.417<0.001
麻醉方式3 513.340349.3010.10610.058<0.001
人工晶体类型
软性球面三片式单焦点非散光型参照组----
软性非球面一片式单焦点非散光型45.230125.7120.0050.3600.719
软性非球面一片式单焦点散光型2 590.090369.6650.0787.007<0.001
软性非球面一片式连续视程非散光型10 496.020369.6650.31628.393<0.001
软性非球面一片式三焦点非散光型21 889.810275.5990.93079.426<0.001
住院天数353.27936.2630.1039.742<0.001
), ArticleFig(id=1241342468982100741, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241342460698349886, language=CN, label=表4, caption=

住院费用多因素线性回归分析结果

, figureFileSmall=null, figureFileBig=null, tableContent=
变量名称非标准化偏回归系数标准化偏回归系数βt值P值
β标准误
常数6 710.562147.755-45.417<0.001
麻醉方式3 513.340349.3010.10610.058<0.001
人工晶体类型
软性球面三片式单焦点非散光型参照组----
软性非球面一片式单焦点非散光型45.230125.7120.0050.3600.719
软性非球面一片式单焦点散光型2 590.090369.6650.0787.007<0.001
软性非球面一片式连续视程非散光型10 496.020369.6650.31628.393<0.001
软性非球面一片式三焦点非散光型21 889.810275.5990.93079.426<0.001
住院天数353.27936.2630.1039.742<0.001
), ArticleFig(id=1241342469116318477, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241342460698349886, language=EN, label=Table 5, caption=

The selection cost burden of different types of intraocular lens

, figureFileSmall=null, figureFileBig=null, tableContent=
人工晶体类型中选价（元）使用数量（片）最高负担金额a及比例/元（%）
个人统筹基金
软性球面三片式单焦点非散光型850.008255（30.00）731（86.00）
软性非球面一片式单焦点非散光型1 300.00203390（30.00）1 118（86.00）
软性非球面一片式单焦点散光型3 190.0011 930（60.50）1 548（48.53）
软性非球面一片式连续视程非散光型11 066.0019 806（88.61）1 548（13.99）
软性非球面一片式三焦点非散光型22 999.99221 739.99（94.52）1 548（6.73）
), ArticleFig(id=1241342469212787476, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241342460698349886, language=CN, label=表5, caption=

不同类型人工晶体的选择费用负担情况

, figureFileSmall=null, figureFileBig=null, tableContent=
人工晶体类型中选价（元）使用数量（片）最高负担金额a及比例/元（%）
个人统筹基金
软性球面三片式单焦点非散光型850.008255（30.00）731（86.00）
软性非球面一片式单焦点非散光型1 300.00203390（30.00）1 118（86.00）
软性非球面一片式单焦点散光型3 190.0011 930（60.50）1 548（48.53）
软性非球面一片式连续视程非散光型11 066.0019 806（88.61）1 548（13.99）
软性非球面一片式三焦点非散光型22 999.99221 739.99（94.52）1 548（6.73）
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人工晶体集中带量采购政策下老年性白内障手术患者单病种结算费用及影响因素研究
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彭勇华 1, 2 , 姚卫光 2
现代预防医学 | 卫生政策与管理 2024,51(4): 674-679
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现代预防医学 | 卫生政策与管理 2024, 51(4): 674-679
人工晶体集中带量采购政策下老年性白内障手术患者单病种结算费用及影响因素研究
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彭勇华1, 2, 姚卫光2
作者信息
  • 1.暨南大学附属第一医院设备科，广东 广州 510630
  • 2.南方医科大学卫生管理学院

    • 彭勇华(1992—)，男，硕士在读，研究方向：社会医学与卫生事业管理

通讯作者:

姚卫光，E-mail：
Study on the single-disease settlement cost and influencing factors of age-related cataract surgery patients under the centralized volume-based procurement policy of intraocular lens
Yong-hua PENG1, 2, Wei-guang YAO2
Affiliations
  • Department of Medical Equipment, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong 510630, China
出版时间: 2024-02-25 doi: 10.20043/j.cnki.MPM.202310236
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摘要
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目的

对人工晶体集中带量采购政策下的老年性白内障手术患者单病种结算费用及影响因素进行研究，为优化费用结构和控制医疗费用增长以及完善人工晶体材料限额付费政策提供相应的理论建议和数据支撑。

方法

收集广州某省属三级甲等公立综合医院眼科2021年6月1日至2022年4月30日收治的215例老年性白内障手术患者的病案资料及单病种结算费用信息，采用描述性分析、新灰色关联分析和建立多因素线性回归模型分析单病种结算费用的构成、影响因素以及人工晶体材料费负担情况。

结果

治疗费、人工晶体费和诊断费是构成老年性白内障手术患者住院费用的主要费用类型（占比分别为52.12%、19.79%、13.56%，合计占85.47%），同时也是影响次均住院费用的主要费用类型（关联度分别为1.000、0.751、0.717）；多因素线性回归分析显示，住院天数、麻醉方式（以局部麻醉为参照，全身麻醉β=3 513.340）和人工晶体类型（以软性球面三片式单焦点非散光型为参照，软性非球面一片式单焦点散光型β=2 590.090，软性非球面一片式连续视程非散光型β=10 496.020，软性非球面一片式三焦点非散光型β=21 889.810）是住院费用的影响因素（P<0.001）；人工晶体材料费医保限额支付下，所选人工晶体单价≤最高限额标准（1 800元）时患者最高负担比例较低，所选人工晶体单价>最高限额标准（1 800元）时患者最高负担比例随着人工晶体价格的增加而增加。

结论

人工晶体集中带量采购政策下老年性白内障手术患者住院费用结构趋于合理，医务人员劳务价值得以体现，但后续应重点关注人工晶体费和诊断费的变化。缩短住院天数、合理选择麻醉方式、合理选择不同类型的人工晶体以及降低人工晶体价格可有效降低老年性白内障手术患者住院费用。根据属地医保基金承受能力适当上调人工晶体材料费限额标准有助于减轻手术患者费用负担。

老年性白内障  /  住院费用  /  影响因素  /  人工晶体  /  单病种
Objective

To study the single-disease settlement cost and its influencing factors for age-related cataract surgery patients under the centralized volume-based procurement policy of intraocular lens, and to provide theoretical suggestions and data support for optimizing the cost structure, controlling the growth of medical costs, and improving the quota payment policy of intraocular lens materials.

Methods

The medical records and single-disease payment information of 215 age-related cataract patients admitted to the Department of Ophthalmology of a provincial tertiary public general hospital in Guangzhou from June 1, 2021 to April 30, 2022 were collected. Descriptive analysis, new grey correlation analysis and multiple linear regression model were used to analyze the composition and influencing factors of single-disease settlement expenses and the burden of intraocular lens materials.

Results

The treatment cost, intraocular lens cost and diagnosis cost were the main types of hospitalization expenses for age-related cataract surgery patients (accounting for 52.12%, 19.79% and 13.56% respectively, accounting for 85.47% in total). At the same time, it was also the main type of expense affecting the average hospitalization expense per time (the correlation coefficients were 1.000, 0.751, 0.717). Multiple linear regression analysis showed that the length of hospital stay, anesthesia type (local anesthesia as the reference, general anesthesia β=3 513.340) and intraocular lens type (soft spherical three-piece monofocal non-astigmatism type as the reference, soft aspheric one-piece monofocal astigmatism type β=2 590.090; soft aspheric one-piece continuous visual field non-astigmatism type β=10 496.020, soft aspheric one-piece trifocal non-astigmatism type β=21 889.810) were the influencing factors of hospitalization expenses (P<0.001). Under the medical insurance limit payment of intraocular lens material fee, the proportion of the highest burden of patients is low when the selected intraocular lens unit price is less than the maximum limit standard (1 800 yuan), and the proportion of the highest burden of patients increases with the increase of the price of intraocular lens when the selected intraocular lens unit price is more than the maximum limit standard (1 800 yuan).

Conclusion

The structure of hospitalization expenses for age-related cataract surgery becomes more reasonable under the centralized volume-based procurement policy of intraocular lens, and the labor value of medical staff is realized. However, more attention should be paid to the changes of intraocular lens costs and diagnostic fees in the future. Shortening the length of hospital stay, reasonable selection of anesthesia methods, reasonable selection of different types of intraocular lens and reducing the price of intraocular lens can effectively reduce the hospitalization cost of age-related cataract surgery patients. Appropriately raising the fee limit of intraocular lens materials according to the affordability of local medical insurance fund is helpful to reduce the cost burden of surgical patients.

Age-related cataract  /  Hospitalization expenses  /  Influencing factors  /  Intraocular lens  /  Single-disease
彭勇华, 姚卫光. 人工晶体集中带量采购政策下老年性白内障手术患者单病种结算费用及影响因素研究. 现代预防医学, 2024 , 51 (4) : 674 -679 . DOI: 10.20043/j.cnki.MPM.202310236
Yong-hua PENG, Wei-guang YAO. Study on the single-disease settlement cost and influencing factors of age-related cataract surgery patients under the centralized volume-based procurement policy of intraocular lens[J]. Modern Preventive Medicine, 2024 , 51 (4) : 674 -679 . DOI: 10.20043/j.cnki.MPM.202310236
正文
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白内障是我国主要致盲性眼病[1]，通过植入人工晶体取代原浑浊晶体的手术方法是目前治疗白内障唯一有效的方法。白内障各分型中以老年性白内障为主，其患病率伴随着年龄的增加而增加[2]。最新老龄人口数据显示[3]，我国已进入中度老龄化社会[4]，并且随着老龄化程度的持续加深，未来将逐步过渡至重度老龄化社会，届时老年人口规模将达到最大值，同时也可以预见老年性白内障患病人数将会不断增多，将会带来较大的医药负担。
全面推行以按病种（DRG/DIP）付费为主的多元复合式医保支付方式是我国当前医保支付方式改革的主要内容，单病种付费是其中不可缺少的部分。既往研究显示使用高价格的人工晶体容易造成DRG组亏损[5]，根据DIP的基础原理可知人工晶体价格对分值影响较大，由此可看出适用于白内障手术的单病种限额付费的医保支付方式在当前仍具有存在和发展的意义。
广州自2012年11月1日起实施眼白内障摘除及人工晶体植入术指定手术单病种付费（适用于职工医保和居民医保），历经药品和耗材零加成、人工晶体省际联盟集中带量采购等政策的落地实施，并将很快进入人工晶体国家集中带量采购[6]的新时期。基于当前医保支付压力剧增的控费要求，叠加老年性白内障患病人数快速增长的公共卫生难题，有必要对人工晶体集中带量采购常态化开展下的老年性白内障手术患者单病种结算费用及影响因素进行深入研究分析，以期为优化费用结构和控制医疗费用增长以及完善人工晶体材料限额付费政策提供相应的理论建议和数据支撑。
1　资料与方法
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1.1　一般资料
广州自2021年5月1日起执行人工晶体类医用耗材联盟地区（广东、河南及江西）集团带量采购中选结果，2021年合同周期为2021年5月1日至2022年4月30日。考虑到政策执行存在一定的过渡期，故排除2021年5月的数据，以2021年6月1日至2022年4月30日作为研究周期，并将研究周期内的数据定义为2021年全年数据。
选取广州某省属三级甲等公立综合医院作为样本医院，收集样本医院眼科收治的出院主要诊断为老年性白内障（ICD-10：H25）且行单眼“白内障超声乳化抽吸术+白内障摘除伴人工晶体一期置入术”（ICD-9-CM-3：13.41+13.71）患者的病案资料。排除标准：①行双眼手术；②非单病种结算；③有严重合并疾病或并发症需行手术或转科治疗；④所使用人工晶体非集中带量采购中选品种；⑤病案首页部分信息填写错误、费用数据异常。
1.2　费用构成分类
参考病案首页费用的分类并结合实际，将住院费用的构成分为药品费、综合医疗服务费、诊断费、治疗费、康复费、人工晶体费、其他医用材料费共7个类型。
1.3　人工晶体分类
参考中国人工晶状体分类专家共识（2021年）[7]并结合实际使用情况，将人工晶体分为5个类型：①软性球面三片式单焦点非散光型；②软性非球面一片式单焦点非散光型；③软性非球面一片式单焦点散光型；④软性非球面一片式连续视程非散光型；⑤软性非球面一片式三焦点非散光型。
1.4　研究方法
1.4.1　新灰色关联分析法
参考既往文献[8]，以次均住院费用作为参考数列X0(k)，以药品费等7个费用类型的次均费用作为比较数列Xi(k)；计算差序数列，即Δi(k)=|Xi(k)-X0(k)|，得出差序列绝对值中的最大值Δmax和最小值Δmin；然后计算关联系数，分辨系数ρ取0.5；最后计算关联度及关联序。
1.4.2　统计学方法
利用EXCEL 2010建立数据库，采用IBM SPSS 21对数据资料进行统计学分析。住院费用经正态检验呈偏态分布，计量资料以中位数（四分位数）的形式描述；住院费用的构成以均数（构成比）的形式描述。对病例的人口学特征和住院费用的构成等情况进行描述性分析，通过构建多因素线性回归模型筛选住院费用的影响因素。以P<0.05为差异具有统计学意义。
2　研究结果
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2.1　研究对象人口学特征
共纳入215例老年性白内障手术患者，男性95例，男女比例为1:1.26；中位年龄为72.00（64.00,76.00）岁，以60岁以上人群（占88.84%）为主，其中70~79岁年龄段占比最高（50.70%），其次是60~69岁年龄段（28.37%）。
2.2　次均住院费用构成分析
纳入研究的215例患者住院费用中位数为7 522.57（7 274.32，7 704.77）元，均数为7 778.45元，次均住院费用构成中排名前三的费用类型依次是治疗费（52.12%）、人工晶体费（19.79%）、诊断费（13.56%），三者合计占85.47%，是次均住院费用的主要构成部分。以医保类型对患者进行分类分析，结果显示职工医保患者次均住院费用略高于居民医保患者4.1个百分点，但二者的次均住院费用的主要构成部分均保持一致且比例相近（85.63%：84.83%）。详见表1。
2.3　次均住院费用与各项费用的关联程度分析
结果显示，与老年性白内障手术患者次均住院费用关联程度最大的是治疗费（1.000），其次是人工晶体费（0.751）和诊断费（0.717），是影响次均住院费用的主要费用类型。以医保类型对患者进行分类分析，结果显示治疗费、人工晶体费、诊断费仍是关联程度较大的费用类型。详见表2。
2.4　住院费用多因素线性回归分析
以住院费用作为因变量，以性别、年龄、医保类型、其他诊断疾病数量、麻醉方式、人工晶体类型、住院天数、是否临床路径管理共8个变量作为自变量，采用逐步法筛选自变量（纳入标准为α=0.05、剔除标准为α=0.10），建立多因素线性回归模型。各变量赋值情况（如是无序多分类变量则进行哑变量设置，采用全部进入的方法筛选自变量）如表3所示。
构建的多因素线性回归模型F=1 472.780，P<0.001，模型具有统计学意义，调整决定系数R2=0.976，说明拟合的回归模型较好。结果显示，与人工晶体类型为软性球面三片式单焦点非散光型相比，人工晶体类型为软性非球面一片式单焦点散光型患者的住院费用较低（β=2 590.090，P<0.001），人工晶体类型为软性非球面一片式三焦点非散光型患者的住院费用较高（β=21 889.810，P<0.001）。与麻醉方式为局部麻醉相比，麻醉方式为全身麻醉患者的住院费用较高（β=3 513.340，P<0.001）。住院天数越长住院费用越高（β=353.279，P<0.001）。详见表4。
2.5　限额支付下不同类型人工晶体的选择费用负担分析
广州医保规定人工晶体植入术单病种所使用的人工晶体材料费纳入统筹基金支付范围的最高限额为1 800元/个。当选择的人工晶体单价≤1 800元时，患者最高负担比例较低，当选择的人工晶体单价>1 800元时，患者最高负担比例随着人工晶体价格的增加而增加。详见表5。
3　讨论与建议
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3.1　住院费用结构趋于合理，但后续应重点关注人工晶体费和诊断费的变化
本研究结果显示，可体现技术劳务价值的医疗服务费用（治疗费+综合医疗服务费+康复费）在住院费用的构成比超55%，优于2021年度全国三级公立医院的27.96%[9]和人工晶体带量采购下的北京某三甲综合医院老年性白内障医保患者的42.57%[10]，基本达到部分省份公立医院高质量发展的指标要求（浙江[11]：不低于35%，青海[12]：逐步提高至60%），说明住院费用结构趋于合理。
人工晶体费和诊断费为非技术劳务性费用，二者在住院费用的占比超30%，对费用结构的变化起到决定性作用（因治疗费相对固定），故应在后续重点关注并采取相应措施以确保费用结构更能体现技术劳务价值，如扩大集中带量采购的规模以降低人工晶体费用，持续优化和推进临床路径、通过规范诊疗过程促进医务人员合理检查和合理治疗。
3.2　缩短住院天数，减少医疗资源消耗
通常情况下，住院天数增加意味着医疗资源消耗的增加，医疗费用也同步增加。本研究发现开展临床路径管理的省属样本医院平均住院天数为2.11天（中位数：2.00天），低于2021年全国省属综合医院的平均住院日2.3天、但高于2021年全国委属综合医院的平均住院日1.9天[13]，说明仍需继续优化诊疗流程和临床路径缩短患者住院时间。同时，样本医院应以新建投入使用的日间手术中心为契机积极探索开展白内障日间手术，以此达到降低住院天数和医疗费用[14]的目的。
3.3　合理选择麻醉方式
白内障手术的麻醉方式一般为局部麻醉，费用相对较低，但麻醉方式的选择除依据手术要求外还会结合患者身体情况和个人意愿等方面综合考虑[15]故也会存在选择全身麻醉的可能。本研究发现全身麻醉患者住院费用高于局部麻醉患者，原因可能是全身麻醉的收费标准远高于局部麻醉的费用，此外，全身麻醉及复苏等所花费的时间也间接延长了住院时间进而导致了医疗费用的增加。
3.4　人工晶体材料费限额支付政策对控费起到促进作用，根据属地医保基金承受能力适当提高限额标准有助于减轻手术患者费用负担
随着科技的进步，白内障手术已逐步从复明性手术过渡到屈光性手术[16]。但本研究结果显示，手术患者主要选择的是单价在医保限额范围内的基本款的人工晶体，而高配版的屈光性人工晶体则较少选择，间接说明人工晶体材料费医保限额支付政策对控制医疗费用增长起到了促进作用，医保基金支付压力得以减轻。
随着人民生活水平的提高，白内障患者对视觉质量的要求及术后生活质量的追求也越来越高，可以预见未来将有不少患者选择价格相对较高的屈光性人工晶体；此外，高端人工晶体目前尚无法像冠脉支架实现国产替代。因此，相关部门应出台相关政策鼓励和支持国内企业提升创新研发技术水平以实现高端人工晶体产业自主[17]；在医疗保障上，医保基金尚无能力承受“基本医疗”需求以外的费用，但后续可在人工晶体国家集中带量采购中选价格基础上根据属地医保基金承受能力适当上调限额标准以减轻患者费用负担；在使用选择上，不应以价格高低作为选择晶体的“金标准”，而应由术者在术前对患者有一个全方位的了解[16]后再进一步确定相对合适的晶体类型。
基金
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  • 广东省高校哲学社会科学重点实验室项目(2015SWSYS0010)
  • 广州公共卫生服务体系建设研究基地资助项目(2021-2023)
文献
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参考文献 引证文献
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2024年第51卷第4期
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doi: 10.20043/j.cnki.MPM.202310236
  • 接收时间：2023-10-17
  • 首发时间：2026-03-19
  • 出版时间：2024-02-25
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  • 收稿日期：2023-10-17
基金
广东省高校哲学社会科学重点实验室项目(2015SWSYS0010)
广州公共卫生服务体系建设研究基地资助项目(2021-2023)
作者信息
    1.暨南大学附属第一医院设备科，广东 广州 510630
    2.南方医科大学卫生管理学院

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2种不同金属材料的力学参数
科
Family		 属数
Number of
genus		 种数
Number of
species		 占总种数比例
Percentage of
total species (%)		 属
Genus		 种数
Number of
species		 占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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