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Article(id=1241522922976768919, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1241522919977841545, articleNumber=null, orderNo=null, doi=10.20043/j.cnki.MPM.202309290, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1694880000000, receivedDateStr=2023-09-17, revisedDate=null, revisedDateStr=null, acceptedDate=null, acceptedDateStr=null, onlineDate=1773931731218, onlineDateStr=2026-03-19, pubDate=1710000000000, pubDateStr=2024-03-10, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1773931731218, onlineIssueDateStr=2026-03-19, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1773931731218, creator=13701087609, updateTime=1773931731218, updator=13701087609, issue=Issue{id=1241522919977841545, tenantId=1146029695717560320, journalId=1227665162245664772, year='2024', volume='51', issue='5', pageStart='769', pageEnd='960', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1773931730503, creator=13701087609, updateTime=1773931880386, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1241523548695622547, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1241522919977841545, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1241523548695622548, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1241522919977841545, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=797, endPage=802, ext={EN=ArticleExt(id=1241522923270370209, articleId=1241522922976768919, tenantId=1146029695717560320, journalId=1227665162245664772, language=EN, title=Analysis of risk factors and construction of risk prediction model for readmission of schizophrenic patients, columnId=1240413921954295836, journalTitle=Modern Preventive Medicine, columnName=Epidemiology and Statistical Methods, runingTitle=null, highlight=null, articleAbstract=
Objective

To explore the risk factors of re-admission of schizophrenic patients within one year after discharge and to establish a risk prediction model of re-admission.

Methods

By using cluster sampling, 353 inpatients with schizophrenia in a large mental hospital from July to December 2020 were collected from the in-patient electronic medical record and discharge follow-up system. Based on their demographic and clinical data, Logistic regression analysis was used to analyze the risk factors of re-admission within one year after discharge.

Results

Four predictive factors were included: course of disease ≥ 20 years (OR=2.373, 95%CI: 1.242-4.533), combination of antipsychotics (OR=2.07, 95%CI: 1.211-3.538), underlying disease (OR=1.893, 95%CI: 1.111-3.226), and harmful behavior (OR=11.219, 95%CI: 5.544-22.701). The prediction model fitted well (χ2 =3.444, P=0.903): the area under the receiver operating characteristic curve of the subjects was 0.805, the sensitivity was 82.6%,and the specificity was 65.6%. The results of Bootstrap re-sampling (n=1 000 times) showed that the model was stable.

Conclusion

The predictive model based on demographic and clinical data can be used as a tool to identify the schizophrenic patients at high risk of re-admission in the early stage.

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目的

探讨精神分裂症患者出院一年内再入院的危险因素并构建再入院风险预测模型。

方法

采用整群抽样，从住院电子病历和出院随访系统中获得某大型精神病院2020年7—12月住院精神分裂症患者353例，基于其人口学和临床资料采用logistic回归分析出院一年内再入院的危险因素，构建与评价再入院风险预测模型并进行内部验证。

结果

最终纳入4个预测因子：病程≥20年(OR=2.373, 95%CI: 1.242～4.533)、抗精神病联合用药(OR=2.07, 95%CI: 1.211～3.538)、合并基础疾病(OR=1.893, 95%CI: 1.111～3.226)、危害性行为(OR=11.219, 95%CI: 5.544～22.701)。所构建的预测模型拟合良好(χ2=3.444, P=0.903)，受试者工作特征曲线下面积为0.805，灵敏度为82.6%，特异度为65.6%。经Bootstrap重抽样(n=1 000次)结果显示模型稳定性良好。

结论

基于人口学和临床资料构建的预测模型可作为早期识别精神分裂症患者再入院高风险的工具。

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王军，E-mail:；
陈琼妮，E-mail:
, copyrightStatement=本刊刊出的所有文章不代表中华预防医学会和本刊编委会的观点，除非特别声明。, copyrightOwner=中华预防医学会和四川大学华西公共卫生学院, extLink=null, articleAbsUrl=null, sourceXml=a4m+Fpc8oYALurCnp9KgjQ==, magXml=NXg7vk+7bizsZ63Kxidh9w==, pdfUrl=null, pdf=UGG7s9DGJnfzRXFOWPfHiA==, pdfFileSize=851914, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=5cLHk990YkN45OyQ32yGCw==, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=5bilH4lwOMY99LOeJu+ntg==, mapNumber=null, authorCompany=null, fund=null, authors=

侯明如（1986—），男，硕士，副主任护师，研究方向：精神疾病临床护理与管理，精神疾病长期照护模式

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侯明如（1986—），男，硕士，副主任护师，研究方向：精神疾病临床护理与管理，精神疾病长期照护模式

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侯明如（1986—），男，硕士，副主任护师，研究方向：精神疾病临床护理与管理，精神疾病长期照护模式

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Comparison of sociodemographic data between RPS and NRPS ［n（%）］

, figureFileSmall=null, figureFileBig=null, tableContent=
因素类别总数
（n=353）		再入院
（n=109）		未再入院
（n=244）		χ2/t值P值
性别男188 (53.3)68 (62.4)120 (49.2)5.2770.022
女165 (46.7)41 (37.6)124 (50.8)
年龄组别（岁）≤ 2017 (4.8)8 (7.3)9 (3.7)1.796#0.180
21～40170 (48.2)51 (46.8)119 (48.8)
41～60151 (42.8)49 (45.0)102 (41.8)
≥ 6115 (4.2)1 (0.9)14 (5.7)
文化程度初中及以下145 (41.1)44 (40.4)101 (41.4)0.0330.856
高中及以上208 (58.9)65 (59.6)143 (58.6)
工作无225 (63.7)75 (68.8)150 (61.5)3.4700.176
退休/病退55 (15.6)18 (16.5)37 (15.2)
在职73 (20.7)16 (14.7)58 (23.4)
婚姻单身230 (65.2)75 (68.8)155 (63.5)0.9260.336
在婚123 (34.8)34 (31.2)89 (36.5)
户口城市(镇)293 (83.0)96 (88.1)197 (80.7)2.8740.090
农村60 (17.0)13 (11.9)47 (19.3)
家庭照料者有295 (83.6)93 (85.3)202 (82.8)0.3520.553
无58 (16.4)16 (14.7)42 (17.2)
家族史阳性69 (19.5)20 (18.3)49 (20.1)0.1440.704
阴性284 (80.5)89 (81.7)195 (79.9)
医疗保险无80 (22.7)22 (20.2)58 (23.8)0.5530.457
有273 (77.3)87 (79.8)186 (76.2)
), ArticleFig(id=1241678325341540876, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241522922976768919, language=CN, label=表1, caption=

两组社会人口学资料比较［n（%）］

, figureFileSmall=null, figureFileBig=null, tableContent=
因素类别总数
（n=353）		再入院
（n=109）		未再入院
（n=244）		χ2/t值P值
性别男188 (53.3)68 (62.4)120 (49.2)5.2770.022
女165 (46.7)41 (37.6)124 (50.8)
年龄组别（岁）≤ 2017 (4.8)8 (7.3)9 (3.7)1.796#0.180
21～40170 (48.2)51 (46.8)119 (48.8)
41～60151 (42.8)49 (45.0)102 (41.8)
≥ 6115 (4.2)1 (0.9)14 (5.7)
文化程度初中及以下145 (41.1)44 (40.4)101 (41.4)0.0330.856
高中及以上208 (58.9)65 (59.6)143 (58.6)
工作无225 (63.7)75 (68.8)150 (61.5)3.4700.176
退休/病退55 (15.6)18 (16.5)37 (15.2)
在职73 (20.7)16 (14.7)58 (23.4)
婚姻单身230 (65.2)75 (68.8)155 (63.5)0.9260.336
在婚123 (34.8)34 (31.2)89 (36.5)
户口城市(镇)293 (83.0)96 (88.1)197 (80.7)2.8740.090
农村60 (17.0)13 (11.9)47 (19.3)
家庭照料者有295 (83.6)93 (85.3)202 (82.8)0.3520.553
无58 (16.4)16 (14.7)42 (17.2)
家族史阳性69 (19.5)20 (18.3)49 (20.1)0.1440.704
阴性284 (80.5)89 (81.7)195 (79.9)
医疗保险无80 (22.7)22 (20.2)58 (23.8)0.5530.457
有273 (77.3)87 (79.8)186 (76.2)
), ArticleFig(id=1241678326213956112, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241522922976768919, language=EN, label=Table 2, caption=

Comparison of clinical data between RPS and NRPS ［n（%），M（P25，P75）］

, figureFileSmall=null, figureFileBig=null, tableContent=
因素类别总数
（n=353）		再入院
（n=109）		未再入院
（n=244）		χ2/t值P值
疾病分型偏执型169 (47.9)43 (39.4)126 (51.6)4.4860.034
其他型184 (52.1)66 (60.6)118 (48.4)
基础疾病有152 (43.1)55 (50.5)97 (39.8)3.5210.061
无201 (56.9)54 (49.5)147 (60.2)
病程分组(月)≤ 120136 (38.5)34 (31.2)102 (41.8)6.552#0.010
121～239114 (32.3)33 (30.3)81 (33.2)
≥ 240103 (29.2)42 (38.5)61 (25.0)
抗精神病药物(种)1170 (48.2)40 (36.7)130 (53.3)8.2970.004
≥ 2183 (51.8)69 (63.3)114 (46.7)
情绪稳定剂有86 (24.4)32 (29.4)54 (22.1)2.1350.144
无267 (75.6)77 (70.6)190 (77.9)
LOS (d)-44 (29, 59.5)46 (33, 58.5)42 (28, 60.75)-1.4390.150
LOS分组(d)≤ 30101 (28.6)24 (22.0)77 (31.6)0.890#0.346
31～59167 (47.3)60 (55.0)107 (43.9)
≥ 6085 (24.1)25 (22.9)60 (24.6)
危害性行为发生202 (57.2)97 (89.0)105 (43.0)65.011<0.001
未发生151 (42.8)12 (11.0)139 (57.0)
阴性症状(出院时)典型291 (82.4)103 (94.5)188 (77.0)15.838<0.001
不典型62 (17.6)6 (5.5)56 (23.0)
ITAQ (出院时，分)≤ 7162 (45.9)53 (48.6)109 (44.7)0.472#0.492
≥ 8191 (54.1)56 (51.4)135 (55.3)
), ArticleFig(id=1241678327019262494, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241522922976768919, language=CN, label=表2, caption=

两组临床资料比较［n（%），M（P25，P75）］

, figureFileSmall=null, figureFileBig=null, tableContent=
因素类别总数
（n=353）		再入院
（n=109）		未再入院
（n=244）		χ2/t值P值
疾病分型偏执型169 (47.9)43 (39.4)126 (51.6)4.4860.034
其他型184 (52.1)66 (60.6)118 (48.4)
基础疾病有152 (43.1)55 (50.5)97 (39.8)3.5210.061
无201 (56.9)54 (49.5)147 (60.2)
病程分组(月)≤ 120136 (38.5)34 (31.2)102 (41.8)6.552#0.010
121～239114 (32.3)33 (30.3)81 (33.2)
≥ 240103 (29.2)42 (38.5)61 (25.0)
抗精神病药物(种)1170 (48.2)40 (36.7)130 (53.3)8.2970.004
≥ 2183 (51.8)69 (63.3)114 (46.7)
情绪稳定剂有86 (24.4)32 (29.4)54 (22.1)2.1350.144
无267 (75.6)77 (70.6)190 (77.9)
LOS (d)-44 (29, 59.5)46 (33, 58.5)42 (28, 60.75)-1.4390.150
LOS分组(d)≤ 30101 (28.6)24 (22.0)77 (31.6)0.890#0.346
31～59167 (47.3)60 (55.0)107 (43.9)
≥ 6085 (24.1)25 (22.9)60 (24.6)
危害性行为发生202 (57.2)97 (89.0)105 (43.0)65.011<0.001
未发生151 (42.8)12 (11.0)139 (57.0)
阴性症状(出院时)典型291 (82.4)103 (94.5)188 (77.0)15.838<0.001
不典型62 (17.6)6 (5.5)56 (23.0)
ITAQ (出院时，分)≤ 7162 (45.9)53 (48.6)109 (44.7)0.472#0.492
≥ 8191 (54.1)56 (51.4)135 (55.3)
), ArticleFig(id=1241678327702934053, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241522922976768919, language=EN, label=Table 3, caption=

Variables assignment

, figureFileSmall=null, figureFileBig=null, tableContent=
变量性质编码
再入院(Y)二分类1=是，0=否
性别(X1)二分类1=男，0=女
户口类型(X2)二分类1=城镇，0=农村
病程(X3)有序三分类2=≥20年，1=10.1～19.9年，0=≤10年
疾病分型(X4)二分类1=偏执型，0=其他
合并基础疾病(X5)二分类1=是，0=否
危害性行为(X6)二分类1=有，0=无
阴性症状(X7)二分类1=典型，0=不典型
药物治疗方案(X8)二分类1=APP，0=AMP
LOS (X9)有序三分类2=≥60 d，1=31～59 d，0=≤30 d
ITAQ (X10)有序二分类1=≥8分，0=≤7分
), ArticleFig(id=1241678328285942315, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241522922976768919, language=CN, label=表3, caption=

变量赋值

, figureFileSmall=null, figureFileBig=null, tableContent=
变量性质编码
再入院(Y)二分类1=是，0=否
性别(X1)二分类1=男，0=女
户口类型(X2)二分类1=城镇，0=农村
病程(X3)有序三分类2=≥20年，1=10.1～19.9年，0=≤10年
疾病分型(X4)二分类1=偏执型，0=其他
合并基础疾病(X5)二分类1=是，0=否
危害性行为(X6)二分类1=有，0=无
阴性症状(X7)二分类1=典型，0=不典型
药物治疗方案(X8)二分类1=APP，0=AMP
LOS (X9)有序三分类2=≥60 d，1=31～59 d，0=≤30 d
ITAQ (X10)有序二分类1=≥8分，0=≤7分
), ArticleFig(id=1241678328625680948, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241522922976768919, language=EN, label=Table 4, caption=

Multivariate Logistic regression analysis for 1-year re-admission in patients with schizophrenia (Backward: LR)

, figureFileSmall=null, figureFileBig=null, tableContent=
变量回归系数标准误Waldχ2值OR值(95%CI)P值
危害性行为无基准组
有2.4180.36045.19811.219 (5.544～22.701)<0.001
病程(年)≤10基准组
10.1～19.90.0730.3280.0491.076 (0.566～2.044)0.824
≥200.8640.3306.8512.373 (1.242～4.533)0.009
药物治疗方案AMP基准组
APP0.7270.2747.0722.070 (1.211～3.538)0.008
合并基础疾病否基准组
是0.6380.2725.5071.893 (1.111～3.226)0.019
常数项-4.2560.60449.7080.014<0.001
), ArticleFig(id=1241678329481318976, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1241522922976768919, language=CN, label=表4, caption=

精分患者出院一年内再入院多因素logistic回归分析（向后逐步）

, figureFileSmall=null, figureFileBig=null, tableContent=
变量回归系数标准误Waldχ2值OR值(95%CI)P值
危害性行为无基准组
有2.4180.36045.19811.219 (5.544～22.701)<0.001
病程(年)≤10基准组
10.1～19.90.0730.3280.0491.076 (0.566～2.044)0.824
≥200.8640.3306.8512.373 (1.242～4.533)0.009
药物治疗方案AMP基准组
APP0.7270.2747.0722.070 (1.211～3.538)0.008
合并基础疾病否基准组
是0.6380.2725.5071.893 (1.111～3.226)0.019
常数项-4.2560.60449.7080.014<0.001
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精神分裂症患者再入院危险因素分析与风险预测模型构建
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侯明如 1 , 王军 2 , 薛建华 3 , 李现文 4 , 陈琼妮 5
现代预防医学 | 流行病与统计方法 2024,51(5): 797-802
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现代预防医学 | 流行病与统计方法 2024, 51(5): 797-802
精神分裂症患者再入院危险因素分析与风险预测模型构建
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侯明如1, 王军2 , 薛建华3, 李现文4, 陈琼妮5
作者信息
  • 1.江南大学附属精神卫生中心，江苏 无锡 214151
  • 2.江南大学附属精神卫生中心临床心理科，江苏 无锡 214151
  • 3.华东疗养院科教处
  • 4.南京医科大学护理学院
  • 5.中南大学湘雅二医院临床护理学教研室，湖南 长沙 410011

    • 侯明如（1986—），男，硕士，副主任护师，研究方向：精神疾病临床护理与管理，精神疾病长期照护模式

通讯作者:

王军，E-mail:；
陈琼妮，E-mail:
Analysis of risk factors and construction of risk prediction model for readmission of schizophrenic patients
Ming-ru HOU1, Jun WANG2 , Jian-hua XUE3, Xian-wen LI4, Qiong-ni CHEN5
Affiliations
  • Department of General Psychiatry, The Affiliated Mental Health Center of Jiangnan University, Wuxi, Jiangsu 214151, China
出版时间: 2024-03-10 doi: 10.20043/j.cnki.MPM.202309290
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摘要
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目的

探讨精神分裂症患者出院一年内再入院的危险因素并构建再入院风险预测模型。

方法

采用整群抽样，从住院电子病历和出院随访系统中获得某大型精神病院2020年7—12月住院精神分裂症患者353例，基于其人口学和临床资料采用logistic回归分析出院一年内再入院的危险因素，构建与评价再入院风险预测模型并进行内部验证。

结果

最终纳入4个预测因子：病程≥20年(OR=2.373, 95%CI: 1.242～4.533)、抗精神病联合用药(OR=2.07, 95%CI: 1.211～3.538)、合并基础疾病(OR=1.893, 95%CI: 1.111～3.226)、危害性行为(OR=11.219, 95%CI: 5.544～22.701)。所构建的预测模型拟合良好(χ2=3.444, P=0.903)，受试者工作特征曲线下面积为0.805，灵敏度为82.6%，特异度为65.6%。经Bootstrap重抽样(n=1 000次)结果显示模型稳定性良好。

结论

基于人口学和临床资料构建的预测模型可作为早期识别精神分裂症患者再入院高风险的工具。

精神分裂症  /  精神病再入院  /  危险因素  /  风险预测模型  /  预防
Objective

To explore the risk factors of re-admission of schizophrenic patients within one year after discharge and to establish a risk prediction model of re-admission.

Methods

By using cluster sampling, 353 inpatients with schizophrenia in a large mental hospital from July to December 2020 were collected from the in-patient electronic medical record and discharge follow-up system. Based on their demographic and clinical data, Logistic regression analysis was used to analyze the risk factors of re-admission within one year after discharge.

Results

Four predictive factors were included: course of disease ≥ 20 years (OR=2.373, 95%CI: 1.242-4.533), combination of antipsychotics (OR=2.07, 95%CI: 1.211-3.538), underlying disease (OR=1.893, 95%CI: 1.111-3.226), and harmful behavior (OR=11.219, 95%CI: 5.544-22.701). The prediction model fitted well (χ2 =3.444, P=0.903): the area under the receiver operating characteristic curve of the subjects was 0.805, the sensitivity was 82.6%,and the specificity was 65.6%. The results of Bootstrap re-sampling (n=1 000 times) showed that the model was stable.

Conclusion

The predictive model based on demographic and clinical data can be used as a tool to identify the schizophrenic patients at high risk of re-admission in the early stage.

Schizophrenia  /  Psychiatric re-admission  /  Risk factor  /  Risk prediction model  /  Prevention
侯明如, 王军, 薛建华, 李现文, 陈琼妮. 精神分裂症患者再入院危险因素分析与风险预测模型构建. 现代预防医学, 2024 , 51 (5) : 797 -802 . DOI: 10.20043/j.cnki.MPM.202309290
Ming-ru HOU, Jun WANG, Jian-hua XUE, Xian-wen LI, Qiong-ni CHEN. Analysis of risk factors and construction of risk prediction model for readmission of schizophrenic patients[J]. Modern Preventive Medicine, 2024 , 51 (5) : 797 -802 . DOI: 10.20043/j.cnki.MPM.202309290
正文
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精神分裂症（schizophrenia）是一种病因未明、反复发作的重性精神疾病，已成为我国主要劳动力年龄段致残的十大病种之一[1]。研究报道，精神分裂症一年复发率为20%～50%[2]，首次治愈的精神分裂症患者（简称精分患者）超过50%呈反复发作，复发再入院引起的疾病总负担日益增加[3-4]。非计划性再入院（简称再入院），是指前次住院诊疗结束，患者在出院后无法预测的再入院，且再入院的原因是相同或相关疾病[5]。研究显示，精分患者一年再入院率为35%～50%[6]，这不仅加重了患者社会性隔离，也容易造成医疗资源的挤兑和浪费。
数据表明，“去机构化”等手段并不能有效改善精分患者再入院问题，其再入院发生率在国内外反有上升趋势[7-9]，亟需进一步探明其再入院危险因素。一项系统评价结果显示[10]，特定的社会人口学变量（如性别、年龄等）和临床特征（如诊断、症状特点等）可能是患者再入院的重要影响因素，但既往研究结果间异质性大。研究还表明再入院风险因素可能存在地区差异。例如，一项在北京开展的研究[11]和另一项在成都开展的研究[12]所发现的风险因素截然不同，这不仅反映了精分患者再入院关联因素的复杂性[10]，也强调了在不同地区和时间框架下[11-13]开展更多类似研究的必要性。
利用再入院风险因素构建成可供临床使用的工具同样是降低患者再入院率的关键举措。Vigod等[13]利用大样本数据（n=65 798）构建了一个名为READMIT指数的精神病患者再入院风险预测模型，发现该模型对出院后30 d内再入院的预测能力良好，这为本领域后续研究提供了框架。当前国内相关研究主要聚焦于分析再入院原因及影响因素，而对再入院风险预测模型的关注不足。综上，本研究选取了一个地域代表性较强的人群样本，分析影响精分患者再入院的关键因素，并进一步构建和验证其出院一年内再入院风险的预测模型，以期为临床早期识别与干预提供参考，最终降低这一人群的再入院率。
1　资料与方法
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1.1　研究对象
根据既定的入组标准，采取整群抽样法对2020年7月1日—12月31日期间所有在江南大学附属精神卫生中心住院的患者进行筛查，以获取本研究所需的被试。纳入标准：（1）符合《国际疾病分类》（第10版）（international classification of diseases, 10th; ICD-10）精神分裂症诊断标准；（2）入院时年龄18～65岁；（3）经抗精神病药物治疗好转后遵医嘱出院；（4）无锡市常住人口，自愿进入出院随访服务系统。排除标准：（1）合并精神活性物质滥用或依赖（烟草除外）及其他重性精神疾病；（2）合并心、脑、肾等严重躯体疾病；（3）资料不全或来源不可靠，如流浪者；（4）涉及司法犯罪。基于研究目的，临床上两种特殊情形[14-15]予以剔除：一是因个人事务办理出院，事后再次入院；二是住院时间（length of stay, LOS）≤72 h（急诊留观）或≥1年（长期住院）。本研究方案获得江南大学附属精神卫生中心伦理委员会批准（WXMHCIRB2022LLky085）。
基于文献回顾及前期相关研究结果[15]，共纳入包含性别、年龄、婚姻、诊断、基础疾病、病程、抗精神病药物、精神症状等18个潜在因素。有研究显示[11]，我国精分患者一年内再入院率为30%左右。根据样本含量估算公式：，其中再入院率P=30%，检验水准α=0.05，进行双侧检验时，容许误差设δ=0.05，算得N=323人，考虑到无效资料，扩大5%～10%的样本量，则所需样本量340～358人。本研究实际符合纳入标准共363例，符合排除标准者10例（2.8%），最终样本量为353例。
1.2　研究方法
1.2.1　再入院的判定
广义上的再入院包括因所有原因而再次入院，参照既往研究[16-17]，本研究中特指非计划性再入院，主要特征：患者病情好转出院后，因疾病复发、恶化等原因再次入院；再入院的第一诊断与上一次出院诊断相同，即精神分裂症；再入院时间具有不可预测性，即并非提前计划好，亦非因外出检查、办理公私事务等原因临时出院后再次入院。
1.2.2　研究工具
自制资料收集表由多名研究人员共同讨论确定，内容包括：（1）社会人口学资料：性别、年龄、文化、工作、婚姻、户口、家庭结构、付费方式等。（2）临床资料：出入院时间、诊断、精神病家族史、基础疾病、起病年龄、治疗用药等。（3）阳性与阴性症状量表（positive and negative symptoms scale, PANSS）含阳性症状7项、阴性症状7项和精神病理症状16项，总分30～210分，分数越高，症状越重[18]；自知力与治疗态度问卷（insight and treatment attitudes questionnaire, ITAQ）含11个条目，总分0～22分，分数越高，自知力越完整[19]。（4）再入院情况：再入院时间、入院经过和原因等。
1.2.3　资料收集与质量控制
课题组于2022年5—7月采取调阅系统和电话沟通的方式获取资料，并对关键环节进行质量控制，主要步骤：（1）课题组主要成员从住院电子病历中获取2020年7—12月住院精分患者的住院号和姓名，然后由两名研究人员根据既定标准选取被试，分别回顾病程、护理和量表评定等记录并逐一审核，准确填写收集表。（2）由两名经过培训的专科护士查阅出院随访系统，若有再入院，则收集入院时间和主要原因等；若无再入院记录，便及时与家属电话沟通并确认。（3）为确保资料真实可靠，课题组主要成员对所填资料进行交叉审核，若遇到疑问，如两次住院的人口学资料不一致，则及时与调查者沟通并向家属核实。（4）所得资料及时录入电脑，经双人交叉校对以确保无逻辑错误、无遗漏。
1.2.4　变量定义
参照既往研究[15,20-21]对部分变量进行定义：（1）单身指入院前无配偶，包括未婚、离婚、丧偶和分居。（2）医疗保险包括城市职工基本医疗保险、居民基本医疗保险、新型农村合作医疗计划和其他保险类型。（3）家庭照料者是指愿意提供无偿照顾并对患者负责的人，包括配偶、父母、孩子、兄弟姐妹和其他亲属。（4）基础疾病指符合内科疾病诊断标准且接受相应药物治疗的基础病，如高血压病、糖尿病、高脂血症。（5）抗精神病联合用药（antipsychotic poly-pharmacy, APP）[22]指出院时联用两种及以上抗精神病药物的处方方案，仅用一种抗精神病药物治疗为单一用药（antipsychotic mono-pharmacy, AMP）。（6）危害性行为指在入院及住院期间发生了自伤、自杀、攻击行为。
1.3　统计学分析
使用SPSS 26.0软件进行统计分析。对于正态或近似正态分布的定量资料用（）描述，采用独立样本t检验；不符合正态分布的计量资料用中位数（四分位数间距）描述，采用Mann-Whitney U检验；定性资料用频数、百分数描述，采用Pearson χ2检验。采用logistic回归模型进行多因素分析和构建风险预测模型，通过Hosmer-Lemeshow（H-L）检验和曲线下面积（area under the curve, AUC）评价模型的拟合优度和预测能力。参照既往类似研究[15,21]，将单因素分析中P<0.1变量纳入多因素分析，采用方差膨胀系数（variance inflation Factor, VIF）评估多重共线性，VIF>2.5判定自变量存在共线性。采用R Studio 4.2.2软件绘制受试者操作特征（receiver operating characteristic, ROC）曲线，并采取自助抽样Bootstrap法（n=1 000次）对模型验证，检验水准α=0.05。
2　结果
收起
2.1　出院一年内再入院
所有被试出院一年内共发生145次再入院，其中1次79例（72.5%），2次22例（20.2%），3次及以上8例（7.5%）。一年内再入院患者中男性68例（62.4%），平均年龄（38.87±11.77）岁，单身75例（68.8%），无业93例（85.3%），有医疗保险87例（79.8%），合并基础疾病55例（50.5%），无家庭照料者16例（14.7%）。出院一年内再入院时间窗：30 d内占3.7%，3个月内占11.3%，6个月内占18.1%，1年内占30.9%。
2.2　两组社会人口学资料比较
对出院后一年内再入院组和未再入院组的社会人口学资料进行比较，发现仅性别有统计学差异（χ2=5.277，P=0.022），其余均无（P>0.05）。见表1。
2.3　两组临床资料比较
对两组临床资料进行比较发现，疾病分型、病程、抗精神病药物种类、危害性行为和阴性症状的组间差异有统计学差异（P<0.05），其余无统计学差异（P>0.05）。见表2。
2.4　精分患者出院一年内再入院的多因素分析
单因素分析中共有8个变量的组间比较P<0.1，表1、2显示，虽然住院时长、自知力的组间差异不显著，但既往文献[10-11]较一致地报道其可能为精分患者再入院的风险因素，因此将上述10个变量均纳入后续分析。根据经验法则，多因素分析时自变量数量不宜超过较少事件组样本量的10%。本研究中较少事件组（再入院组）的样本量为109例，故符合要求。变量赋值见表3。
各变量VIF值为1.003～1.186，可排除共线性，采用向后逐步回归法分析结果显示，病程≥20年、联合用药、合并基础疾病、有危害性行为是精分患者出院一年内再入院的独立危险因素，见表4。
2.5　精分患者出院一年内再入院风险预测模型的构建及效果分析
以多因素分析结果作为预测因子，构建风险预测模型公式：P=1/1+exp [-(2.418×危害性行为+0.864×病程≥20年+0.727×APP+0.638×合并基础疾病-4.256)]。以截断值为检验变量，以是否再入院为状态变量绘制ROC曲线，结果显示，AUC=0.805 (95%CI: 0.759～0.85)，P<0.001，表明预测模型预测效果良好。H-L检验结果为（χ2=3.444, P=0.903），表明模型能较好地拟合再入院的实际发生情况。以约登指数最大值判断预测模型的最佳临界值，ROC曲线的最大约登指数为0.482，最佳阈值（cutoff值）为0.286，此时敏感度为82.6%，特异度为65.6%。见图1。
Bootstrap重抽样（n=1 000次）结果显示AUC均值为0.8，方差为0.000 529，说明模型稳定性较好，见图2。
3　讨论
收起
3.1　精分患者出院一年内再入院的危险因素分析
本研究显示，精分患者出院一年内再入院的重要危险因素依次是：有危害性行为、病程≥20年、联合用药、合并基础疾病。再入院组存在危害行为的比例是未再入院组的2.1倍（89% vs. 43%），由于攻击行为不仅威胁人身安全，也容易造成家庭关系紧张和支持系统下降[23]，故而增加再住院可能性。伴有危害性行为者通常为非自愿住院，既往研究表明非自愿或强制性住院患者发生再入院的概率会大幅增加[10,13,24]，本研究结果与此相符，也进一步提示对于既往有过暴力/自伤危害行为的患者在出院把关和出院后监管方面需要采用更加严格的标准。
精神分裂症一般起病于青壮年，病程慢性迁延，社会功能逐渐衰退，本研究中位病程为156个月，其中病程≥20年者伴有被动/淡漠、社交退缩等典型症状高达80%，其出院后较难适应社会生活，再入院风险也会增加。另外，病程≥20年者平均起病年龄小于病程≤10年者（22.8岁vs.25.9岁），而起病年龄被认为是再入院的影响因素[25]，这提示要加强对长病程慢性患者的情感支持与调节以及社会功能训练。
联合使用抗精神病药物者再入院风险是单一用药的2.1倍。药物治疗仍是我国精神分裂症主要治疗方案，且需要长期治疗。一项系统评价显示，亚洲各国针对精神分裂症APP治疗使用率高达50%[26]，本研究中联合使用抗精神病药物者占51.8%。当单一治疗不足以控制症状或病情恶化时，便开始联合治疗，但联合治疗并不都是有益的[27]，选择不当可能会增加药物潜在副作用，联合治疗组患者出院后服药依从性可能更差，复发再入院机率也会增加。这提示要对出院患者的治疗方案进行权衡和优化，减少不必要的联合用药，并在过渡期间重视药物知识宣教、评估和监管。
本研究精分患者再入院≥2次者合并基础疾病占53.3%，再入院1次者占49.4%，而未再入院者占39.8%。一项系统评价显示，如果精神障碍患者合并躯体疾病，再入院风险会随之增加[9]，可能原因是躯体疾病本身会促使精神症状和/或病程的恶化，而精神症状对身心状态有着独立的附加效应，这一观点与De等[28]研究一致。因此，出院前除了评估精神症状外，同时要对阳性体征和异常检验值以及患者不适主诉加以评估与鉴别，早识别早干预，并进行随访和追踪。
3.2　精分患者一年内再入院风险预测模型的评价
一项针对急性精神疾病患者出院30 d内再入院风险建立了一个具有中等鉴别能力的预测模型（c-statistic=0.63），其涵盖了7个预测因子[13]。相比较而言，本研究所建立的临床预测模型可能更优，而且该模型仅涵盖了4项出院前静态指标，资料获取方便、操作简单，经内部验证显示出良好的鉴别性能与稳定性，经进一步论证和优化后有望形成可供精神科临床使用的工具，用于对精分患者出院前进行筛查，以早期发现再入院高风险患者进而协助制订后续干预策略。
本研究尚存在一定局限性，如未纳入既往住院次数、出院后因素等，缺少外部验证，未来可纳入多维度因素如近期负性生活事件、社会支持利用度等进一步分析，并经外部验证模型的适用性和外推性，持续对模型进行修订和改善，进而为改良出院准备服务方案提供依据。
基金
收起
  • 无锡市卫士健康委科研项目(M202255)
文献
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doi: 10.20043/j.cnki.MPM.202309290
  • 接收时间：2023-09-17
  • 首发时间：2026-03-19
  • 出版时间：2024-03-10
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  • 收稿日期：2023-09-17
基金
无锡市卫士健康委科研项目(M202255)
作者信息
    1.江南大学附属精神卫生中心，江苏 无锡 214151
    2.江南大学附属精神卫生中心临床心理科，江苏 无锡 214151
    3.华东疗养院科教处
    4.南京医科大学护理学院
    5.中南大学湘雅二医院临床护理学教研室，湖南 长沙 410011

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