CN113222365A - Clinical pathway design and evaluation method, system, medium, device and application - Google Patents
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Abstract
The invention belongs to the field of information management technology and clinical scientific research design, and discloses a disease management clinical path design and evaluation method, a system, a medium, equipment and application, wherein a clinical path is designed from a limited key problem; determining key problems and priorities of incorporating path design; combing the core problem of the path and generating path units; constructing a path unit, and visually evaluating the clinical applicability and the clinical management effect of the path design through the actual working mode of the path; calculating the actual functional boundaries of the pathway design in the specific disease management; and an external study plan using a wedge ladder design evaluates the stepwise improved pathway design step by step until the pathway design achieves the best cost-effectiveness of current disease management. The invention can control the actual working mode of the path by ensuring the transparency of the path design process, realize the optimal medical cost benefit of disease management, help to continuously improve the clinical path management disease level and close the gap between the evidence and the practice.
Description
Technical Field
The invention belongs to the field of information management technology and clinical scientific research design, and particularly relates to a disease management clinical path design and evaluation method, system, medium, equipment and application.
Background
At present: the key path method of manufacturing management introduces the project or production project management concept into the medical industry from the 20 th century and 80 th century to generate clinical paths and is rapidly widely popularized and applied in the medical and health fields of all countries in the world. An intervention is considered a clinical pathway for disease management if it meets the following four criteria: 1) it is a structured multidisciplinary care plan; 2) it is used to import guidelines or evidence into local structures; 3) it specifies steps in the treatment or care process (i.e., intervening time frames or criteria-based progression) in a plan, path, algorithm, guideline, protocol, or other "action list"; 4) it is intended to standardize care for specific clinical problems, procedures or care events in a specific population. The national government and health organization aim to organize research evidence into local medical health workflow through a disease management clinical path, so that the research evidence becomes an important tool which can directly improve medical quality, standardize diagnosis and treatment flow and control medical cost. However, as an implementation strategy, the study and improved implementation of clinical pathways is fraught with complexity and challenges. The clinical pathway has a different outcome in a realistic clinical setting than the overall therapeutic outcome of all interventions in a relatively controlled trial setting. When the implementation of a clinical pathway fails, it is important to know whether the failure is due to one or more critical interventions in the clinical pathway design being ineffective in the new environment (intervention strategy failure) or good intervention deployments (implementation strategy failure). Such knowledge is crucial to engaging research and practice to effectively implement validated interventions to improve health outcomes. Clinical pathway design rudiments for existing disease management are generated by multidisciplinary team discussion, and design tools are lacked to ensure the transparency of pathway design. In addition, because the actual working mode of the clinical pathway cannot be determined, the factors influencing the implementation effect of the clinical pathway are many, complex and uncontrollable, the factors are difficult to control and analyze by common queue research or random contrast research design, and finally, only the pathway management effect can be comprehensively measured and compared, the reported research result cannot be determined to be the effectiveness of the clinical pathway, the effectiveness and the cause-and-effect relationship of the pathway components cannot be further explored and provide insight, and valuable feedback information cannot be provided for the rationality of resource configuration and the applicability of evidence.
Through the above analysis, the problems and defects of the prior art are as follows: absent a theoretical understanding of the clinical pathway implementation process itself, neither the design nor assessment of the clinical pathway can achieve simultaneous attention to both the pathway operational results and the operational process. The existing clinical pathway prototype for disease management lacks a design tool to ensure the transparency of pathway design, the feasibility of pathway implementation is poor, the evaluability of pathway implementation effect is poor, and a feedback mechanism of evidence applicability and resource allocation rationality is lacked, so that the functions of regulating medical behaviors, controlling the whole medical cost, maintaining or improving the medical quality and reasonably allocating resources through clinical disease pathway management cannot be realized finally. .
The difficulty in solving the above problems and defects is: the function and the operation mode of a clinical path need to be further understood by developing and implementing scientific basic theories, the essential difference of manufacturing industry management such as disease clinical management, production and sale needs to be analyzed, the reason that the design thought of the manufacturing industry management path is not feasible is recognized, the fundamental problem of the disease clinical management path is traced, the bottom logic of the current obstacle is cleared, the reality is understood from the fundamental needs of people after the disease, and the design thought and the evaluation method capable of solving the fundamental problem are re-established.
The significance of solving the problems and the defects is as follows: the basic theory for implementing science is further developed by applying the marginal cost and marginal benefit basic theory of micro-economics, a general system theory and a mathematical entropy increase law and combining with the evidence-following medical thought, and the basic theory for implementing science is helped to further understand the function and the operation mode of the clinical path from the perspective of the whole sanitary system, which is the basis for implementing research and improvement of the clinical path. The designer can master the actual operation mode of the clinical path, find the bottleneck problem of path management in time and continuously improve the bottleneck problem, so that the disease management clinical path really realizes the functions of standardizing medical behaviors, controlling the whole medical cost, maintaining or improving the medical quality and reasonably allocating resources, and finally helps the country and people to realize the maximum health by purchasing the limited resources.
Disclosure of Invention
Aiming at the problems in the prior art, the invention provides a clinical pathway design and evaluation method, a system, a medium, equipment and application.
The invention is realized in such a way that a clinical pathway design and evaluation method comprises the following steps:
the clinical path is designed and gradually improved from limited key problems;
determining key problems and priorities of incorporating path design;
combing the core problem of the path and generating path units;
constructing a path unit, and visually evaluating the clinical applicability of path design through the actual working mode of the path;
calculating the actual functional boundaries of the pathway design in the specific disease management;
evaluating the clinical effect of path design implementation by utilizing the calculation of marginal cost and marginal benefit;
an external research scheme employing a tapered staircase design evaluates the step-by-step improved path design in stages.
Further, the clinical pathway is designed and refined from limited key questions, including:
(1) calculating according to the actual functional boundary of the path management system, and determining the current optimal path design scheme according to the marginal profit and marginal cost of a specific scene;
(2) starting with a limited key problem, path design is carried out, and when a management effect is started, a differentiated marginal cost and marginal benefits (including expansion of an actual functional boundary) are brought when the complexity of each differential is increased in the path design, and even the marginal cost can be increased in a negative direction due to reduction of absolute medical cost;
(3) as the path design is more and more perfect, the marginal profit begins to decrease when approaching the upper limit, and when the marginal profit is equal to the marginal cost, the path design achieves optimization, namely the difference between the total profit and the total cost is maximum;
(4) as path designs continue to improve and become more complex, higher marginal costs are required if the same units of revenue are to be increased. When the marginal cost is larger than the marginal benefit, the increasing speed of the total cost is larger than the total benefit, and the intersection point of the total benefit curve and the total cost curve represents the path design with the net benefit being zero.
Further, when determining the key problems and priorities of the included path design, the criticality and the priorities of specific problems need to comprehensively analyze the research priority setting of the problems, the magnitude of the measure effect values in the research and the evidence quality of the measure effect values;
from the perspective of the path functioning, the problem that the benefit of disease management and/or the control cost can be significantly increased after the solution is solved is regarded as a key problem for determining the functioning of the path management effect, and the greater the functioning, the higher the criticality and the higher the priority.
Further, when the core problem of the path is combed and a path unit is generated, it is known that not every link in the disease management activities is a key problem to be solved, and the core problem is divided into 3 types for combing according to the criticality of the problem of every link:
1) a critical path unit: the key problem is to generate a key path unit, which is a key decision link for controlling the clinical management cost-benefit of the disease, and the cost-effect of the disease diagnosis and treatment is likely to be obviously influenced. It is emphasized that determining ineffective but not recommended practices should still be demonstrated in the pathway, as not performing them is likely to significantly impact overall disease management cost-effectiveness, unless these practices are generally recognized and widely accepted as non-core practices. (ii) a
2) The conventional path unit: some diagnosis and treatment activities are standard operations which are commonly known in current clinical practice or basic operations without recommendation suggestions, and the diagnosis and treatment activities generate conventional path units which can not obviously influence the cost-effect of current disease diagnosis and treatment but are essential core steps of the diagnosis and treatment activities, so that the core diagnosis and treatment idea logic of path design is complete and reasonable. The method of recognizing such problems/path elements is: if not done so, it will be strange and unmistakable. (ii) a
3) Disputed path unit: some links of diagnosis and treatment activities are possibly critical, cost-effect of disease diagnosis and treatment can be obviously influenced if the links are solved, but effective solving measures are lacked at present, the prior management measure clinical guidelines recommend opinions, disputed path units are generated due to the uncertain problems of disputed clinical decision schemes, path designers only need to identify and inform people of uncertainty, and do not need to forcibly recommend intervention measures, because the fact that the path designers have no practical significance or even have no execution possibility, and the clinical treatment can be carried out according to the prior actual operation program. The method can be used as a disputed decision link of the whole clinical path, can support the completeness of diagnosis and treatment ideas in path design, can not obviously influence the evaluation of the application effects of the whole path and other path units before being effectively solved, marks the evaluation to enable unsolved problems to be clear at a glance, and further recognizes the direction of improvement of future disease management research. .
Further, the constructing a path unit and evaluating the clinical applicability of the path design through the visualization of the actual working mode of the path comprises the following steps:
(1) each path unit is constructed by people and diagnosis and treatment measures;
(2) with the implementation of path management, the sequential solution of the core problem gradually stratifies the crowd into the crowd with more and more detailed characteristics step by step until the crowd has a certain ending;
(3) the path units which are linked in a ring and are gradual are used for describing diagnosis and treatment problems which are mainly solved in the core step of health management, solutions which are recommended based on evidence and expected diagnosis and treatment effects, and finally a management plan which is made for specific diseases based on an evidence chain is formed;
(4) the path units which are buckled by the loops finally form a specific disease management core plan based on evidence, when a patient enters a path, core characteristics and a final clinical outcome appearing after the path entry are sequentially extracted from the medical record of each patient entering the path, and the core characteristics and the node codes corresponding to the clinical outcome are arranged into track codes after the path entry according to the time sequence;
(5) the number of people at each path node and the shunting direction of people after the path is accessed are counted through the track codes containing the time information, the actual working mode of the path can be visualized through data integration and a computer graphic technology, defects and shortcomings of the design are exposed visually compared with the original path design, and the bottleneck of the path design is positioned.
Further, the calculation of the actual functional boundary after the path design is implemented includes:
(1) evaluating indexes of actual functional boundaries after path design implementation: the path entropy. Entropy means invalid energy in a system and is used for measuring the 'inherent chaos degree' of the system, the larger the entropy is, the more disordered the system is, the smaller the entropy is, and the more ordered the system is; the larger the path entropy is, the smaller the applicability of the path to the management target population is, the poorer the path management effect is, and the more disordered the disease management is; the smaller the path entropy is, the greater the path applicability is, the better the path management effect is, and the more orderly the disease management is;
(2) calculation of Path Entropy (PE):
remarking: PE is less than 1 and not less than 0.
i represents the ith level of the longest branch of the path where the node starts from the root node (level 1 node) in the path;
i＝1，2，3，……，G
ki represents that the node is the kth node of the ith level of the longest branch of the located path;
k＝1，2，3，……，Ni
pki represents the probability of stopping at the kth node of the i-th level after the path-managed patient is accessed:
Rkiwhich represents the sum of the number of nodes remaining after the kth node of the ith stage of the path.
Further, the calculation of the marginal cost and the marginal benefit is used for evaluating the clinical effect of the path design implementation, and the method comprises the following steps:
(1) starting with a limited key problem, path design is carried out, and when a management effect is started, a differentiated marginal cost and marginal benefits (including expansion of an actual functional boundary) are brought when the complexity of each differential is increased in the path design, and even the marginal cost can be increased in a negative direction due to reduction of absolute medical cost;
(2) as the path design is more and more perfect, the marginal profit begins to decrease when approaching the upper limit, and when the marginal profit is equal to the marginal cost, the path design achieves optimization, namely the difference between the total profit and the total cost is maximum;
(3) as path designs continue to improve and become more complex, higher marginal costs are required if the same units of revenue are to be increased. When the marginal cost is larger than the marginal benefit, the increasing speed of the total cost is larger than the total benefit, and the intersection point of the total benefit curve and the total cost curve represents the path design with the net benefit being zero.
Further, the external research scheme using the wedge staircase design gradually evaluates the gradual improvement path design in stages, including:
(1) at the beginning of the research/investigation, all groups or groups which are included in the research are not interfered, and one group or one group of groups is randomly selected at regular time intervals to implement a path design scheme;
(2) further adjustments and improvements are made based on earlier performance, and this process is performed in sequence until all clusters or groups have been intervened.
It is a further object of the invention to provide a computer device comprising a memory and a processor, the memory storing a computer program which, when executed by the processor, causes the processor to perform the steps of:
the clinical path is designed and gradually improved from limited key problems;
determining key problems and priorities of incorporating path design;
combing the core problem of the path and generating path units;
constructing a path unit, and visually evaluating the clinical applicability of path design through the actual working mode of the path; calculating the actual functional boundaries of the pathway design in the specific disease management;
evaluating the clinical effect of path design implementation by utilizing the calculation of marginal cost and marginal benefit;
an external research scheme employing a tapered staircase design evaluates the step-by-step improved path design in stages.
It is another object of the present invention to provide a computer-readable storage medium storing a computer program which, when executed by a processor, causes the processor to perform the steps of:
the clinical path is designed and gradually improved from limited key problems;
determining key problems and priorities of incorporating path design;
combing the core problem of the path and generating path units;
constructing a path unit, and visually evaluating the clinical applicability of path design through the actual working mode of the path; functional boundary calculation of path design in specific disease management;
evaluating the clinical effect of path design implementation by utilizing the calculation of marginal cost and marginal benefit;
an external research scheme employing a tapered staircase design evaluates the step-by-step improved path design in stages.
Another object of the present invention is to provide a public health disease management terminal for implementing the clinical pathway design and evaluation method.
Another objective of the present invention is to provide a clinical pathway design and evaluation system for implementing the clinical pathway design and evaluation method, the clinical pathway design and evaluation system comprising:
the clinical path perfecting module is used for designing clinical paths from limited key problems and perfecting the clinical paths step by step;
the key problem and priority determination module is used for determining the key problems and priorities of the included path design;
the path unit generation module is used for combing the core problem of the path and generating a path unit;
the path unit construction module is used for constructing the clinical applicability of the path unit through the visualization evaluation path design of the actual working mode of the path; a functional boundary calculation module for functional boundary calculation of path design in specific disease management;
the marginal cost and marginal benefit calculation module is used for evaluating the clinical effect of path design implementation;
an improved path design module for evaluating the step-by-step improved path design step by step using an external research scheme of a wedge staircase design.
By combining all the technical schemes, the invention has the advantages and positive effects that: the invention provides a design and evaluation thought and method of a clinical path based on the principles of evidence-based medical thought, mathematical law and economics, and aims to ensure the transparency of the path design process and realize the optimal medical cost benefit of disease management by controlling the actual working mode of the path, thereby being beneficial to continuously improving the clinical path management level and closing the evidence of the gap between the evidence and practice.
The invention can abstract the core knowledge of specific disease management from the summary of scattered and isolated system evaluation evidences to form an integral core concept which is convenient and easy to master and use by clinical path design. The clinical path is designed by selecting key links which show that the decision scheme is exact and effective preferentially from the prior evidence, the influence of the implementation of the key links on the overall cost-effect of path management is evaluated in a key way under the condition that other links are fixed, the design of the key links of the path is gradually added on the basis, the evaluation is completed, the refinement of the core management link is pursued, the core management plan of specific diseases is formed, and the public health benefit maximization of the disease management is finally realized.
Comparison of the present invention with the design and evaluation of the traditional clinical management pathway for diseases
Drawings
In order to more clearly illustrate the technical solutions of the embodiments of the present application, the drawings needed to be used in the embodiments of the present application will be briefly described below, and it is obvious that the drawings described below are only some embodiments of the present application, and it is obvious for those skilled in the art that other drawings can be obtained from the drawings without creative efforts.
FIG. 1 is a flow chart of a clinical pathway design and evaluation method provided by an embodiment of the present invention.
Fig. 2 is a schematic diagram of a path design and evaluation scheme provided by an embodiment of the present invention.
FIG. 3 is a graph illustrating the relationship between the marginal benefit and the marginal cost according to an embodiment of the present invention.
FIG. 4 is a flow chart of the generation of path units and the construction of path design according to the embodiment of the present invention.
FIG. 5 is a flow chart of full-chain trajectory tracking and data collection after patient access according to an embodiment of the present invention.
FIG. 6 is a schematic diagram of an external evaluation study plan with stepwise evaluation and refinement of path design provided by an embodiment of the present invention.
FIG. 7 is a conceptual model diagram of a clinical pathway for conducting a study.
FIG. 8 is a two-dimensional diagram defining the actual functional range of a clinical pathway.
Detailed Description
In order to make the objects, technical solutions and advantages of the present invention more apparent, the present invention is further described in detail with reference to the following embodiments. It should be understood that the specific embodiments described herein are merely illustrative of the invention and are not intended to limit the invention.
In view of the problems in the prior art, the present invention provides a method, system, medium, device and application for clinical pathway design and evaluation, and the present invention is described in detail below with reference to the accompanying drawings.
As shown in fig. 1, the clinical pathway designing and evaluating method provided by the embodiment of the present invention includes:
s101: the clinical path is designed and gradually improved from limited key problems;
s102: determining key problems and priorities of incorporating path design;
s103: combing the core problem of the path and generating path units;
s104: constructing a path unit, and visually evaluating the clinical applicability of path design through the actual working mode of the path;
s105: calculating the actual functional boundaries of the pathway design in the specific disease management;
s106: evaluating the clinical effect of path design implementation by utilizing the calculation of marginal cost and marginal benefit;
s107: an external research scheme employing a tapered staircase design evaluates the step-by-step improved path design in stages.
Those skilled in the art can also implement the clinical pathway design and evaluation method provided by the present invention by using other steps, and the clinical pathway design and evaluation method provided by the present invention in fig. 1 is only one specific embodiment.
In step S101 in the present embodiment, contrary to the current pursuit of large and complete clinical pathway design, we consider that it is necessary to start pathway design from the most critical issues for specific disease management, which significantly affect the cost-effectiveness of the disease management, and then gradually add more steps and improve the design based on the effectiveness of pathway design. First, it is not possible to initially design a complete optimal clinical pathway with limitations on disease awareness and gaps between evidence and practice. Second, the clinical pathway is that "rational" people implement disease management systems that use the limited "money" they own to purchase as much health as possible. Not as large and complete systems are suitable for all areas, designers need to consider the actual functional boundaries of the path management system to determine the current optimal path design solution according to the marginal gain (incremental gain) and marginal cost (incremental cost) of a specific scenario (fig. 3). Starting with a limited key problem, path design is performed, and the management effect is at the beginning, a differentiated marginal cost (increment of cost) and a differentiated marginal benefit (increment of benefit) are brought when the complexity of the path design is increased by one, even the marginal cost may be increased in a negative direction due to the reduction of absolute medical cost, the marginal benefit starts to decrease when approaching the upper limit as the path design is more and more perfect, and the path design is optimized when the marginal benefit is equal to the marginal cost, namely the difference between the total benefit and the total cost is the maximum. As path designs continue to improve and become more complex, higher marginal costs are required if the same units of revenue are to be increased. When the marginal cost is greater than the marginal benefit, the overall cost increases more rapidly than the overall benefit. The intersection of the total benefit curve and the total cost curve represents a path design with a net benefit of zero.
In step S102 in the embodiment of the present invention, the path design should primarily consider the problem that the existing valid evidence shows significant impact on the cost effectiveness of the specific disease management. The criticality and priority of a specific problem need to comprehensively consider research priority setting of the problem, the magnitude of a measure effect value in the research and the evidence quality of the measure effect value. From the perspective of the path's functioning, those problems that can significantly increase the revenue and/or cost of disease management when resolved should be considered as critical issues in determining the effectiveness of the path management, with greater effectiveness being more critical and more prioritized. Therefore, a path designer can review a priority order list of a certain disease diagnosis and treatment management key problem from research priority setting of a certain health problem in health organization files, clinical guidelines and system evaluation at all levels, preferentially select the key problem of an existing effective solution to be incorporated into path design, and simultaneously need to consider the quality of evidence. Furthermore, the priority of incorporating problems in path design is inevitably always done in a local specific economic culture context and is influenced by value preference, so it is important for different stakeholders to participate in the discussion and to ensure transparency of the path design process.
In step S103 in the embodiment of the present invention, as a unit for forming a path, a disease management system cannot be formed by isolated and dispersed key problems, and the system needs to be arranged in a combing manner with other core problems of disease management according to a logical idea of medical diagnosis and treatment to form a core management plan for controlling cost-effect of a specific disease, that is, a complete clinical path design. Given that not every link in the disease management activity is a key problem, we sort each link into 3 classes for combing according to the criticality of the problem (fig. 4):
1) a critical path unit: the key problem is to generate a key path unit, which is a key decision link for controlling the clinical management cost-benefit of the disease, and the cost-effect of the disease diagnosis and treatment is likely to be obviously influenced. It is emphasized that determining ineffective but not recommended practices should still be demonstrated in the pathway, as not performing them is likely to significantly impact overall disease management cost-effectiveness, unless these practices are generally recognized and widely accepted as non-core practices. (ii) a
2) The conventional path unit: some diagnosis and treatment activities are standard operations which are commonly known in current clinical practice or basic operations without recommendation suggestions, and the diagnosis and treatment activities generate conventional path units which can not obviously influence the cost-effect of current disease diagnosis and treatment but are essential core steps of the diagnosis and treatment activities, so that the core diagnosis and treatment idea logic of path design is complete and reasonable. The method of recognizing such problems/path elements is: if not done so, it will be strange and unmistakable. (ii) a
3) Disputed path unit: some links of diagnosis and treatment activities are possibly critical, if the links are solved, cost-effect of disease diagnosis and treatment can be obviously influenced, but effective solving measures are lacked at present, the prior management measure clinical guidelines recommend suggestions, disputed uncertain problems of clinical decision schemes generate disputed path units, path designers only need to identify and inform people of uncertainty, and do not need to forcibly recommend intervention measures, because the fact that the path designers have no practical significance or even have no execution possibility, the clinical treatment can be carried out according to the prior actual operation program. The method can be used as a disputed decision link of the whole clinical path, can support the completeness of diagnosis and treatment ideas in path design, can not obviously influence the evaluation of the application effects of the whole path and other path units before being effectively solved, marks the evaluation to enable unsolved problems to be clear at a glance, and further recognizes the direction of improvement of future disease management research.
In step S104 in the embodiment of the present invention, each path unit (a core link of disease management) is constructed by a crowd (path node) and a diagnosis and treatment measure (path node branch). With the implementation of path management, the sequential solution of the core problem (path unit) progressively stratifies the crowd (path root node or first-level node) into crowd with more and more detailed characteristics (path progressive node) until the crowd has some ending (path end node) (fig. 4 and fig. 5).
The path tree diagram formed by the path nodes and the branches can intuitively express a core thought system for disease health management. The path units which are linked in a ring and are gradual are used for describing diagnosis and treatment problems which are mainly solved in the core steps of the sanitation management, solutions which are recommended based on evidence and expected diagnosis and treatment effects, and finally a management plan which is made for specific diseases based on an evidence chain is formed.
The loop-locked pathway units ultimately form an evidence-based specific disease management program. After a patient enters a path, core features and final clinical outcomes appearing after the patient enters the path can be sequentially extracted from a medical record of each patient entering the path, the core features and the node codes corresponding to the clinical outcomes are arranged into path codes after the patient enters the path according to a time sequence, the number of people of each path node can be counted through the path codes containing time information, the shunting direction of the people after entering the path can also be counted, the actual working mode of the path can be visualized through data integration and a graphic technology, defects and shortcomings of the path design can be visually exposed compared with the original path design, the bottleneck of the path design is located, and the possibility is provided for evaluating and improving the clinical applicability of the path design (figure 5).
In step S106 in the embodiment of the present invention, the key point of the path evaluation is the influence of the execution of the critical path unit on the overall cost effectiveness of the path management under the condition that other path units are fixed. Evaluation of the effectiveness of a path design may facilitate improvements in the path design, including adjusting previous critical path elements and/or adding new critical path elements, each of which may require further evaluation. An external research scheme using a wedge step design may allow for a stepwise gradual improvement of the evaluation step by step to perfect the path design. The external evaluation scheme of the step wedge design can realize the gradual evaluation and improvement of the path design so as to find the optimal path design with the maximum net benefit (figure 6). During the initial period of the study, all the groups (or clusters) included in the study do not receive intervention, then one group (or group) is randomly drawn at regular time intervals ("steps" or "step sizes") to implement the path design scheme, and further adjustment and improvement are made according to the previous implementation effect, and the process is carried out in sequence until all the groups (or clusters) receive intervention. Thus, the gradual development, gradual evaluation and gradual improvement of path design can be realized, the time effect of path implementation can be observed, and the heterogeneity of path implementation in different areas can be further analyzed; the effect of the path implementation can be quantitatively evaluated; and the implementation of the path does not need to be completely spread at one time, and a large amount of manpower, material resources and financial resources do not need to be invested instantaneously, so that the waste of resources caused by invalid/inefficient path design is avoided (see fig. 5). Under the current situation that the demand of medical care always exceeds available resources, the design, evaluation and improvement of the path are a process which continuously goes along with time until the related diseases are well controlled, the disease management achieves the maximum public health benefit, namely the difference between the total benefit and the total cost of the path management is the maximum, or the maximum path management benefit which can be supported by local economy.
In the present invention, the calculation of the actual functional boundary after the implementation of the path design includes:
(1) evaluating indexes of actual functional boundaries after path design implementation: the path entropy. Entropy means invalid energy in a system and is used for measuring the 'inherent chaos degree' of the system, the larger the entropy is, the more disordered the system is, the smaller the entropy is, and the more ordered the system is; the larger the path entropy is, the smaller the applicability of the path to the management target population is, the poorer the path management effect is, and the more disordered the disease management is; the smaller the path entropy is, the greater the path applicability is, the better the path management effect is, and the more orderly the disease management is;
(2) calculation of Path Entropy (PE):
remarking: PE is less than 1 and not less than 0.
i represents the ith level of the longest branch of the path where the node starts from the root node (level 1 node) in the path;
i＝1，2，3，……，G
ki represents that the node is the kth node of the ith level of the longest branch of the located path;
k＝1，2，3，……，Ni
pki represents the probability of stopping at the kth node of the i-th level after the path-managed patient is accessed:
Pkiwhich represents the sum of the number of nodes remaining after the kth node of the ith stage of the path.
In the invention, the calculation of marginal cost and marginal benefit is used for evaluating the clinical effect of path design implementation, and the method comprises the following steps:
(1) starting with a limited key problem, path design is carried out, and when a management effect is started, a differentiated marginal cost and marginal benefits (including expansion of an actual functional boundary) are brought when the complexity of each differential is increased in the path design, and even the marginal cost can be increased in a negative direction due to reduction of absolute medical cost;
(2) as the path design is more and more perfect, the marginal profit begins to decrease when approaching the upper limit, and when the marginal profit is equal to the marginal cost, the path design achieves optimization, namely the difference between the total profit and the total cost is maximum;
(3) as path designs continue to improve and become more complex, higher marginal costs are required if the same units of revenue are to be increased. When the marginal cost is larger than the marginal benefit, the increasing speed of the total cost is larger than the total benefit, and the intersection point of the total benefit curve and the total cost curve represents the path design with the net benefit being zero.
As shown in fig. 2, a path design and evaluation scheme. Starting from the definition of clinical problems and scope to be solved by path management, path designers and stakeholders review existing relevant guidelines, paths and system evaluations, formulate a priority list of key problems for batch inclusion path design and form review reports, batch inclusion key problems, sort core problems of paths, generate path units, and draw path prototypes. Developing clinical research to evaluate the path management effect, further improving and perfecting the original path design on the basis of the evaluation result, and performing further evaluation, and circulating the steps until the disease management clinical path design with the maximum public health benefit is obtained.
As shown in FIG. 3, an optimal path design solution is determined based on marginal benefit (incremental gains) and marginal cost (incremental costs). (plotting marginal benefit versus marginal cost).
As shown in fig. 4, the generation of path cells and the construction of path designs. The path design firstly considers the key problem with effective decision basis. The priority-based batches of key questions are incorporated into the path design. The method comprises the steps of classifying core problems in path management, including key problems, controversial problems and conventional problems to generate path units, and forming a path design prototype according to clinical diagnosis and treatment ideas. And taking the crowd as a path node and taking the management measure as a path node branch to construct a path unit.
As shown in fig. 5, full-chain trajectory tracking and data collection after patient access. Based on the design of path nodes by using the core characteristics of the population (including the characteristics and clinical outcome given to patients by core management measures), each path node is given a unique node code, such as: a. b, c' and the trajectory codes after the patient is subjected to the diameter-entering, namely the core characteristics appearing after the patient is subjected to the diameter-entering and the node codes corresponding to the clinical outcome are arranged according to the time sequence, such as: after Blue of a patient with a certain disease (a) enters path management, the actually accepted core management measures are 1, 2 and 5 in sequence, the management effects are 1+, 2 and 5 in sequence, and the clinical outcome is two, so that the track code is abeg; after the Red of the patient enters the path management, the Red actually receives the core management measures 1 and 2 in sequence and then leaves the path, and the management effect is 1+ and 2+ in sequence, so that the track code is abd. By analogy, the track code of patient Orange is abej (r) and the track code of Green is acdh (r). The actual working mode of the path can be visualized by utilizing the track codes.
As shown in fig. 7, which is a conceptual model of the clinical pathway conducting the study. The clinical pathway has a different outcome in a real-world clinical setting than the overall therapeutic effect of the intervention in a relatively controlled trial setting. When a clinical pathway fails to conduct a job, it is important to know whether the failure occurred because one or more critical interventions in the clinical pathway were ineffective in the new environment (intervention strategy failed) or whether good interventions were improperly deployed (implementation strategy failed). Such knowledge is crucial to engaging research and practice to effectively implement validated interventions to improve health outcomes.
As shown in fig. 8, two dimensions of the actual functional range of the clinical pathway are defined. The actual functional extent of the clinical pathway can be reflected in at least two dimensions. The degree of influence of the group/tissue level (group/tissue level dimension) clinical path operation on the group/tissue level disease diagnosis and treatment net benefit is first; second, from the individual level to the tissue level (across the hierarchy dimension), the operation of the clinical pathway changes the overall disease diagnosis process. Pathway Entropy (PE) reflects changes in disease diagnosis and treatment processes after CPW administration.
It should be noted that the embodiments of the present invention can be realized by hardware, software, or a combination of software and hardware. The hardware portion may be implemented using dedicated logic; the software portions may be stored in a memory and executed by a suitable instruction execution system, such as a microprocessor or specially designed hardware. Those skilled in the art will appreciate that the apparatus and methods described above may be implemented using computer executable instructions and/or embodied in processor control code, such code being provided on a carrier medium such as a disk, CD-or DVD-ROM, programmable memory such as read only memory (firmware), or a data carrier such as an optical or electronic signal carrier, for example. The apparatus and its modules of the present invention may be implemented by hardware circuits such as very large scale integrated circuits or gate arrays, semiconductors such as logic chips, transistors, or programmable hardware devices such as field programmable gate arrays, programmable logic devices, etc., or by software executed by various types of processors, or by a combination of hardware circuits and software, e.g., firmware.
The above description is only for the purpose of illustrating the present invention and the appended claims are not to be construed as limiting the scope of the invention, which is intended to cover all modifications, equivalents and improvements that are within the spirit and scope of the invention as defined by the appended claims.
Claims (12)
1. A clinical pathway design and evaluation method, comprising:
the clinical path is designed and gradually improved from limited key problems;
determining key problems and priorities of incorporating path design;
combing the core problem of the path and generating path units;
constructing a path unit, and visually evaluating the clinical applicability of path design through the actual working mode of the path;
calculating the actual functional boundaries of the pathway design in the specific disease management;
evaluating the clinical effect of path design implementation by utilizing the calculation of marginal cost and marginal benefit;
an external research scheme employing a tapered staircase design evaluates the step-by-step improved path design in stages.
2. The clinical pathway design and evaluation method of claim 1, wherein the designing and refining of clinical pathways starting from limited key questions comprises:
(1) calculating according to the actual functional boundary of the path management system, and determining the current optimal path design scheme according to the marginal profit and marginal cost of a specific scene;
(2) starting with limited key problems, path design is carried out, and when the management effect is started, marginal cost and marginal benefits of differentiation are brought when the complexity of the path design is increased by one differentiation, including the expansion of an actual functional boundary, even the marginal cost is increased in a negative direction due to the reduction of absolute medical cost;
(3) as the path design is more and more perfect, the marginal profit begins to decrease when approaching the upper limit, and when the marginal profit is equal to the marginal cost, the path design achieves optimization, namely the difference between the total profit and the total cost is maximum;
(4) as path designs continue to improve and become more complex, higher marginal costs are required if the same units of revenue are to be increased. When the marginal cost is larger than the marginal benefit, the increasing speed of the total cost is larger than the total benefit, and the intersection point of the total benefit curve and the total cost curve represents the path design with the net benefit being zero.
3. The clinical pathway design and evaluation method of claim 1, wherein in determining the key questions and priorities involved in the pathway design, the criticality and priorities of a particular question require a comprehensive analysis of the study priority settings of the questions, the magnitude of the effect values of the measures in the study, and the quality of evidence of the effect values of the measures;
from the perspective of the path functioning, the problem that the benefit of disease management and/or the control cost can be significantly increased after the solution is solved is regarded as a key problem for determining the functioning of the path management effect, and the greater the functioning, the higher the criticality and the higher the priority.
4. The clinical pathway design and evaluation method of claim 1, wherein when the core problem of the combing pathway is generated and the pathway unit is generated, it is known that not every link in the disease management activity is a key problem to be solved, and the problem of each link is classified into 3 types for combing according to its criticality:
1) a critical path unit: the key problem generation key path unit is a key decision link for controlling the clinical management cost-benefit of the disease, and the cost-effect of the disease diagnosis and treatment is probably obviously influenced;
2) the conventional path unit: the method of recognizing such problems/path elements is: if not, the operation will be strange and unsolved;
3) disputed path unit: the problem of dispute in the current solution generates disputed path units, and the disputed decision links as the whole clinical path are kept in the path design to support the completeness of diagnosis and treatment ideas.
5. The clinical pathway design and evaluation method of claim 1, wherein the constructing a pathway unit and evaluating the clinical applicability of the pathway design through the visualization of the actual working mode of the pathway comprises:
(1) each path unit is constructed by people and diagnosis and treatment measures;
(2) with the implementation of path management, the sequential solution of the core problem gradually stratifies the crowd into the crowd with more and more detailed characteristics step by step until the crowd has a certain ending;
(3) the path units which are linked in a ring and are gradual are used for describing diagnosis and treatment problems which are mainly solved in the core step of health management, solutions which are recommended based on evidence and expected diagnosis and treatment effects, and finally a management plan which is made for specific diseases based on an evidence chain is formed;
(4) the path units which are buckled by the loops finally form a specific disease management core plan based on evidence, when the patients enter the path, the core characteristics and the final clinical outcome appearing after the path entering are sequentially extracted from the medical record of each patient entering the path, and the node codes corresponding to the core characteristics and the clinical outcome are arranged into the track codes after the path entering according to the time sequence;
(5) the number of people at each path node and the shunting direction of people after the path is accessed are counted through the track codes containing the time information, the actual working mode of the path can be visualized through data integration and a computer graphic technology, defects and shortcomings of the design are exposed visually compared with the original path design, and the bottleneck of the path design is positioned.
6. The clinical pathway design and assessment method of claim 1 wherein the calculation of the actual functional boundary after the implementation of the pathway design comprises:
(1) evaluating indexes of actual functional boundaries of clinical disease management effects after implementation of path design: path entropy, entropy means invalid energy in a system and is used for measuring the 'internal chaos degree' of the system, the larger the entropy is, the more disordered the system is, and the smaller the entropy is, the more ordered the system is; the larger the path entropy is, the smaller the applicability of the path to the management target population is, the poorer the path management effect is, and the more disordered the disease management is; the smaller the path entropy is, the greater the path applicability is, the better the path management effect is, and the more orderly the disease management is;
(2) calculation of path entropy PE:
remarking: PE is less than 1 and greater than or equal to 0;
i represents the ith level of the longest branch of the path where the node starts from the root node (level 1 node) in the path:
i＝1，2，3，……，G
ki denotes that the node is the kth node of the ith level of the longest branch of the path:
k＝1，2，3，……，Ni
pki represents the probability of stopping at the kth node of the i-th level after receiving path management patient access:
Rkiwhich represents the sum of the number of nodes remaining after the kth node of the ith stage of the path.
7. The clinical pathway design and evaluation method of claim 1 wherein evaluating the clinical outcome of a population level pathway design implementation using calculations of marginal cost and marginal benefit comprises:
(1) starting with limited key problems, path design is carried out, and when the management effect is started, marginal cost and marginal benefits of differentiation are brought when the complexity of the path design is increased by one differentiation, including the expansion of an actual functional boundary, even the marginal cost is increased in a negative direction due to the reduction of absolute medical cost;
(2) as the path design is more and more perfect, the marginal profit begins to decrease when approaching the upper limit, and when the marginal profit is equal to the marginal cost, the path design achieves optimization, namely the difference between the total profit and the total cost is maximum;
(3) as path designs continue to improve and become more complex, higher marginal costs are required if the same revenue units are to be increased; when the marginal cost is larger than the marginal benefit, the increasing speed of the total cost is larger than the total benefit, and the intersection point of the total benefit curve and the total cost curve represents the path design with the net benefit being zero.
8. The clinical pathway design and evaluation method of claim 1, wherein the external study protocol using a wedge staircase design evaluates stepwise improved pathway designs in stages, comprising:
(1) at the beginning of the research/investigation, all groups or groups which are included in the research are not interfered, and one group or one group of groups is randomly selected at regular time intervals to implement a path design scheme;
(2) further adjustments and improvements are made based on earlier performance, and this process is performed in sequence until all clusters or groups have been intervened.
9. A computer device, characterized in that the computer device comprises a memory and a processor, the memory storing a computer program which, when executed by the processor, causes the processor to carry out the steps of:
the clinical path is designed and gradually improved from limited key problems;
determining key problems and priorities of incorporating path design;
combing the core problem of the path and generating path units;
constructing a path unit, and visually evaluating the clinical applicability of path design through the actual working mode of the path; calculating the actual functional boundaries of the pathway design in the specific disease management;
evaluating the clinical effect of path design implementation by utilizing the calculation of marginal cost and marginal benefit;
an external research scheme employing a tapered staircase design evaluates the step-by-step improved path design in stages.
10. A computer-readable storage medium storing a computer program which, when executed by a processor, causes the processor to perform the steps of:
the clinical path is designed and gradually improved from limited key problems;
determining key problems and priorities of incorporating path design;
combing the core problem of the path and generating path units;
constructing a path unit, and visually evaluating the clinical applicability of path design through the actual working mode of the path; functional boundary calculation of path design in specific disease management;
evaluating the clinical effect of path design implementation by utilizing the calculation of marginal cost and marginal benefit;
an external research scheme employing a tapered staircase design evaluates the step-by-step improved path design in stages.
11. A public health disease management terminal, characterized in that, the public health disease management terminal is used for realizing the clinical pathway design and evaluation method of any claim 1-7.
12. A clinical pathway design and evaluation system for implementing the method of any one of claims 1 to 7, comprising:
the clinical path perfecting module is used for designing clinical paths from limited key problems and perfecting the clinical paths step by step;
the key problem and priority determination module is used for determining the key problems and priorities of the included path design;
the path unit generation module is used for combing the core problem of the path and generating a path unit;
the path unit construction module is used for constructing the clinical applicability of the path unit through the visualization evaluation path design of the actual working mode of the path; a functional boundary calculation module for functional boundary calculation of path design in specific disease management;
the marginal cost and marginal benefit calculation module is used for evaluating the clinical effect of path design implementation;
an improved path design module for evaluating the step-by-step improved path design step by step using an external research scheme of a wedge staircase design.
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