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2018~2022 年某三甲眼科专科医院临床诊疗非手术常规血液检验项目分析

Analysis of non-surgical routine blood test items in clinical diagnosis and treatment at a tertiary ophthalmic specialist hospital from 2018 to 2022

来源期刊: 眼科学报 | 2024年2月 第39卷 第2期 99-106 发布时间:2024-02-28 收稿时间:2024/6/6 16:15:10 阅读量:798
作者:
关键词:
眼科检验专科血液检测
ophthalmology clinical laboratory test specialty blood test
DOI:
10.12419/24022206
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目的:分析某三甲眼科专科医院近5年临床诊疗涉及非手术常规血液检验项目的申请检测情况,为眼科医师了解检验辅助诊断概况、专科医院的实验室项目管理和开展新项目提供依据。方法:从中山大学中山眼科中心医学检验信息管理系统导出2018年1月1日至2022年12月31日期间到院申请进行血液检测的12 866例门诊患者的22 453份样本(共94 081项检验项目)相关检验记录。将申请检测科室及专科医师按照中华医学会眼科学分会推荐分为10个亚专科,对疾病诊断和检测项目等资料进行统计分析,采用文字、柱状图及折线图的形式进行描述。结果:5年间申请进行血液检测的12 866例门诊患者,男性患者6 356例(49.4%),女性患者6 510例(50.6%)。基于首诊眼病诊断分类,排名前三位的眼病分别为眼整形/眼肿瘤病5 214例 (40.5%)、眼底病 3 487例(27.1%)、角膜病1 711例(13.3%)。申请检测样本量从2018年的3 163份增至2022年的5 903份,总体呈上升趋势。从申请的专科医师分析,眼整形/眼眶病专科医师申请单最多,有6 751份(占30.1%),其中自身免疫性疾病检测所占比例最高,为49.1%,甲状腺疾病相关检测占41.9%;眼免疫专科医师申请检测量为4 214份(占18.8%),以自身免疫性疾病检测为主占55.7%,感染性项目检测占32.5%;眼底病专科医师申请检测量为3 629份(16.2%),其中自身免疫性疾病检测和感染性项目检测分别占47.8%和39.6%;角膜病专科医师申请数为1 436份(占6.4%),其中过敏性疾病检测比例为41.2%。基于一份申请单可同时检测多个项目,眼整形/眼眶专科申请检测总项最多,有33 513项,甲
状腺疾病检测占65.0%;角膜病专科申请16 482项,过敏性疾病检测占83.4%,眼底病专科和眼免疫专科分别为8 794项和8 047项,均以自身免疫性疾病检测为主,分别占42.5%和40.4%。结论:眼科专科医院中非手术常规检验项目在各亚专科的申请数量明显分布不均,项目构成受亚专科疾病特点的影响。眼科实验室应针对性加强非手术常规检测项目的宣传和管理。
Objective: To analyze the application and testing of non-surgical routine blood test items in clinical diagnosis and treatment in a top-tier ophthalmic hospital over the past five years, providing ophthalmologists with insights into the overview of laboratory-assisted diagnosis, laboratory project management in specialized hospitals, and the basis for launching new projects. Methods: Relevant test records of 22,453 samples (totaling 94,081 test items) from 12,866 outpatient patients who applied for blood tests at the Zhongshan Ophthalmic Center of Sun Yat-sen University from January 1, 2018, to December 31, 2022, were retrieved from the medical laboratory information management system. The departments applying for tests and specialist physicians were divided into 10 subspecialties according to the recommendations of the Ophthalmology Branch of the Chinese Medical Association. Statistical analysis was performed on disease diagnosis and test items, and the results were described in the form of text, bar graphs, and line graphs. Results: Among the 12,866 outpatient patients who applied for blood tests over the five-year period, 6,356 (49.4%) were male and 6,510 (50.6%) were female. Based on the classification of first-visit ophthalmic diseases, the top three were ophthalmic plastic surgery/ocular tumor diseases (5,214 cases, 40.5%), fundus diseases (3,487 cases, 27.1%), and corneal diseases (1,711 cases, 13.3%). The number of samples applied for testing increased from 3,163 in 2018 to 5,903 in 2022, showing an overall upward trend. From the perspective of specialist physicians applying for tests, ophthalmic plastic surgery/orbital disease specialists had the highest number of applications, with 6,751 (30.1%), among which autoimmune disease testing accounted for the highest proportion, at 49.1%, and thyroid disease-related testing accounted for 41.9%. The number of applications from ophthalmic immunology specialists was 4,214 (18.8%), with autoimmune disease testing accounting for 55.7% and infectious disease testing accounting for 32.5%. The number of applications from fundus disease specialists was 3,629 (16.2%), with autoimmune disease testing and infectious disease testing accounting for 47.8% and 39.6%, respectively. The number of applications from corneal disease specialists was 1,436 (6.4%), with allergic disease testing accounting for 41.2%. Since multiple tests could be performed on a single application, the ophthalmic plastic surgery/orbital disease subspecialty had the highest total number of tests applied for, with 33,513 tests, of which thyroid disease testing accounted for 65.0%. The corneal disease subspecialty applied for 16,482 tests, with allergic disease testing accounting for 83.4%. The fundus disease subspecialty and ophthalmic immunology subspecialty respectively applied for 8,794 and 8,047 tests, both primarily focused on autoimmune disease testing, accounting for 42.5% and 40.4%, respectively. Conclusions: The number of applications for non-surgical routine test items in ophthalmic specialized hospitals is significantly unevenly distributed among various subspecialties, and the composition of the items is influenced by the characteristics of diseases in each subspecialty. Ophthalmic laboratories should strengthen the promotion and management of non-surgical routine test items in a targeted manner.

文章亮点

1. 关键发现

  基于数据管理系统的回顾性分析,发现眼科除手术外涉及的全身因素,检测项目与亚专业相关。

2. 已知与发现

  实验室应加强和临床医师的沟通,特别拓展新知识 ( 技术、项目 ) 的学习和积累,促进管理及诊疗水平。
  不同的亚专业和检测有密切的关系,提高针对性的检测,更好地服务患者。

3. 意义与改变

  临床医师了解眼科疾病与检测现状,重视全身相关因素和新技术与眼科的关系,对实验室而言,应不断加强实验室与
临床的沟通,完善诊疗规范,实现个性化检测,更好服务患者。

    眼科疾病多与全身性疾病密切相关[1-4],眼科医师需要根据患者的实验室检查结果,了解患者全身状况,制定个性化的医疗方案[5-6]。因此,针对性进行血液检测非常重要。同时,完善配置实验室与疾病相关的检验项目对眼科临床诊治也至关重要。但眼科疾病的生物学指标繁多,且不同亚专科之间检验项目的需求存在较大差异。受限于中国人口众多而医疗资源存在地区不均的特点[5-7],医院检验项目的开展,既要考虑到能满足临床的需要,也要严格控制人员、设备、耗材等运行成本[8-10]
目前眼部疾病相关的检验项目主要为术前常规检验,但也有一定数量的、为帮助特定眼部疾病诊治而进行的检验。针对我国医疗机构中眼科检验项目开展现状的相关分析报道现尚欠缺,本文回顾性分析了近5年来在中山大学中山眼科中心门诊申请的与术前常规检测不相关的检验项目(简称非术前检验项目)的检测情况,并按照亚专科进行分类统计,旨在为眼科医师了解疾病检验情况及专科医院开展检验项目提供信息指导。

1 资料与方法

1.1 数据来源

本研究是一项回顾性研究,已通过中山大学中山眼科中心伦理委员会审批(批件号:2018KYPJ140-4)。数据来源于中山大学中山眼科中心医学检验信息系统(laboratory information system,LIS)。该信息系统数据真实记录了患者的检测信息。本研究中的非手术常规项目是指除入院手术常规所需的检测项目(血常规、血生化、凝血四项、术前感染项目和尿液检查)以外的血液检验项目。选择对2018年1月1日~2022年12月31日期间的患者进行检索,获取数据。剔除每年职工体检和临床研究中心的筛查数据,患者通过门诊医生工作站申请检测单并抽血检测的数据纳入统计。本研究中的申请为执行有效的检测。

1.2 数据归类与分析

统计申请项目信息,包括患者年龄、性别、申请医师专业和检验项目等条目信息。对于专科及疾病诊断,按照中华医学会眼科学分会(https://ccos2023.sciconf.cn/)推荐,参考笔者之前所报道的方法[11],以主诊断(参考就诊专科)将疾病分类为眼整形/眼眶病、眼底病、角膜病、眼免疫病、青光眼、眼外伤、眼视光、斜弱视、晶状体病及其他(诊断为空白或眼科检查等无法归类项)。本研究参考《全国临床检验操作规程》,将涉及的检验项目分为感染性疾病检测项目和非感染性疾病检测项目(主要包括过敏性检测项目、甲状腺疾病检测项目、自身免疫性疾病检测项目和其他检测项目)[12]。以患者诊疗卡为标识,同一例患者虽有不同的表述诊断但多次诊断基本均为同类眼病,如有不同眼病诊断的以首次诊断统计,多次申请检测分别列入统计,一份申请单统计为一份血样本,可同时检测多个单项。

1.3 统计学分析

将数据导入SPSS 22.0软件进行描述性统计分析,采用文字、图表等方式对结果进行描述。

2 结 果

2.1 基本信息分析

2018年1月1日~2022年12月31日期间,申请进行血液检测的12 866例门诊患者中,男6 356例(占49.4%)、女6 510例(占50.6%)。年龄范围为0~84岁,中位数为34岁(图1)。
图1 2018~2022年申请进行血液检测的12 866位门诊患者的性别及年龄分布
Figure 1 Gender and age distribution of 12 866 outpatient patients who applied for blood testing from 2018 to 2022

2.2 非手术常规血液检测的变化趋势

以标本登记时间为准,截至2022年12月31日共收到22 453份非手术常规血液标本(94 081项)。2018~2022年间,申请进行血液检测的门诊患者占该年门诊患者数(同一患者不重复计算)的百分比分别为:2018年占0.42%(2 323/554 850),2019年占0.42%(2 578/616 904),2020~2022年依次占0.35%(1 660/477 471)、0.52%(3 032/579 908)和0.60%(3 273/545 100)。如图2所示,申请进行血液检测的患者与标本送检数总体呈增长趋势。从2018年的2 323例患者申请3 163份血液标本增至2022年的3 273名患者申请5 903份。另外统计数据中,5年来分别增加了病毒荧光定量(3项)、结核菌感染T细胞、肌酸激酶、乳酸脱氢酶和25-羟基维生素D检测,多为单检测项,而包含29项的过敏性疾病检测样本数减少(由2018年的223份下降到2022年的118份),单项总数由2018年的19 165项下降到2022年的18 652项。
图2 非手术常规血液检测的变化趋势
Figure 2 The trend of changes in non-surgical routine blood testing
5年来申请进行检测的门诊患者和标本数总体增加,每年检测总项目数增加不明显。
The overall number of outpatient patients and specimens applying for testing has increased over the past 5 years, but the increase in the total number of testing items each year is not significant.

2.3 申请进行血液检测的门诊患者眼病总体分布

对申请进行血液检测的12 866例门诊患者眼病的第一诊断进行分类统计(图3),结果显示眼整形/眼眶病人数最多,有5 214例(占40.5%),其次为眼底病,有3 487例(占27.1%),第三位为角膜病,有1 711例(占13.3%),另有眼免疫病、其他(诊断为空白或眼科检查等无法归类项)、青光眼、眼视光、晶体病、眼外伤、斜视病等。
图3 申请进行血液检测的门诊患者病种构成
      Figure 3 Disease composition of outpatient patients applying for blood testing
每例患者仅按第一诊断的病种进行归类统计,居前3位的病种分别是眼整形/眼眶病、眼底病、角膜病。
                Each patient is classified and counted based solely on the first diagnosed disease, with the top three diseases being eye plastic surgery/orbital disease, fundus disease, and corneal disease.

2.4 眼科各亚专科申请检测分析

   从眼科亚专科申请检测数量上分析,眼整形/眼眶病专科申请检测数量最多,共6 751份,包括33 513项单项检测,大幅领先于其他亚专科,其中甲状腺疾病相关检验项目的占比最大,为64.99%。角膜病专科共申请1 436份16 482项单项检测,以过敏性检测项目为主,占83.35%。眼底病专科医师偏向申请自身免疫性疾病检测和感染性抗原、抗体检测,分别占42.48%和41.61%。眼免疫专科医师5年来申请了4 214份共8 047项单项检测,以自身免疫性疾病检测为主,占40.36%(见表1)。

表1 2018~2022年眼科亚专科申请血液检测项目统计

Table 1 Statistics of blood testing projects applied for in ophthalmic subspecialty from 2018 to 2022      [n (%)]

图4 排名前十位的检测项目及检测该项目的患者数、申请次数分布图
Figure 4 The top ten testing items and the distribution chart of the number of patients tested and the number of applications for this item
患者数为5年间申请进行检测该项目的人数,申请次数为申请该项目检测的次数,同一份血液标本可同时检测多个项目,同一患者不同时间多次检测同一项目列入计算。甲状腺功能检测为检测人数及检测次数最多的项目。
The number of patients who have applied for testing this item within 5 years is the number of times they have applied for testing this item. The same blood sample can be tested for multiple items at the same time, and the same patient can be tested for the same item multiple times at different times, which is included in the calculation. Thyroid function testing is the item with the highest number and frequency of tests.

3 讨论

据统计,全球有22亿人患有某种形式的视力障碍和(或)眼病,其中,至少有10亿人患有可预防的视力障碍[13]。眼睛是机体的组成部分之一,多种全身系统性疾病可在眼部有所表现,虽然眼科疾病常独立于全身系统,但部分眼病也受到局部或全身性疾病的影响,因此在治疗过程中也应密切关注患者的相关检验指标[1]。临床实验室通过生化、免疫或分子诊断等方法检测患者体液及组织标本,其结果可为临床眼科医生提供更准确的诊疗信息,也为患者获得个性化诊疗方案提供了可能[14]。目前尚未见关于眼科医师申请实验室检测项目情况的文献报道,本文通过对2018~ 2022年期间中山大学中山眼科中心医师申请的22 453份临床诊疗涉及非手术常规血液检测标本进行分析,初步得出亚专科、疾病诊断和申请检验项目的关系。
近5年来眼科专科针对非手术患者申请血液检测数量趋于增加,说明实验室检验结果在眼科疾病的诊疗过程中越来越受到重视,也有可能与血液检验结果与眼部疾病关联性研究的深入有关。近年来有文献报道葡萄膜炎诊断中关联的实验室指标[15-19]、维生素D浓度与屈光不正相关[20-23]、弓形虫抗原抗体检测与眼病准确率[24-25]、自身免疫性疾病与眼病关系[1, 26-30]、维生素D浓度与屈光不正相关[20-23]、弓形虫抗原抗体检测与眼科疾病[24-25]、自身免疫性疾病与眼科疾病关系[1, 26-30]等。这些必将促进血液检验在眼科疾病诊疗中的应用。
本研究结果中,针对患者、疾病类型、检测项目以及申请医生的统计均显示眼眶病/眼整形相关的检测最多,该专科包含了与全身疾病密切相关的甲状腺相关眼病,医师常进行甲状腺疾病方面的检测。同时眼底病专科医师更想了解患者自身免疫性疾病和感染性抗原、抗体方面的关系,而角膜科医师在过敏性检测项目上申请的检测量最多。以上结果说明临床检验项目的类别受眼科亚专科及眼病诊断的影响较大。另外,结果显示患者数量和样本数随年份增长而增加,项目总数则趋平稳。主要原因可能是感染性检测、甲状腺疾病检测、自身免疫性疾病检测和其他检测中,1份样本平均所含的检测项目约为5项,过敏性疾病检测含有16项,近年来过敏性疾病检测的申请数量有所下降。虽然每年感染性检测和自身免疫性疾病检测有新增项目,但平均年增加数不足10%,新增检测项目包含的项目数没有申请量减少的项目所含的项目数多,即过敏性疾病检测的申请数量减少对总体项目数的影响比新增项目对总体数量影响更大。因此检测范围越来越广,可供临床医师选择的项目增多,血液样本数增加了,但总项目数变化不明显。
本次统计涉及309名医生,其中申请检测数量排名前十位医师大多为高级职称人员,主要来自眼整形/眼眶病和眼底病专科,其他专科医师和综合门诊初级职称医师则较少。从门诊排班及实际情况分析,综合门诊医师基本为初中级职称,工作日和周末均出诊,一般少有手术安排,高级职称医师工作日非全天出诊,一般有手术安排,教学与科研工作较多,出诊量比综合门诊初级职称医师少。造成申请检测量差异的原因可能与该医师的专业和知识背景有关。且与高职称医师工作时间长,与实验室工作交流多,熟悉检测流程等也有关。因此,实验室应加强检测项目在初级职称医师群体中的宣讲。
另外,从专科医院的角度,临床医师希望检验科在现有的检测项目上不断拓宽检测范围,能为患者提供全面的检验项目,减少患者需检测但实验室没有开展该项目而要到其他医院检测后返诊的麻烦,如能针对目前的检测情况进行精细化管理,打造眼科亮点和特色,更能助力临床诊疗。但目前检测项目的开展涉及实验室人员、场地及试剂耗材成本等[8],管理部门需合理管控,不断优化成本管理,总体采用优化流程设计与信息化建设相结合的方式为患者提供更加高效、便捷的医疗服务[31-35]
综上所述,眼科非手术常规血液检测越来越受到眼科医师的重视,检测情况明显受眼科亚专科、医师专业背景及疾病类型影响。本回顾性研究所得到的结果有助于加强眼科医师对眼病全身相关因素的重视,注意拓展新知识、关注新技术和开展新项目。而对临床实验室而言,眼科检验人员应不断加强实验室与临床的沟通,促进管理,完善诊疗规范,特别要关注针对性检测技术的应用及拓展眼科相关项目,这些将更好地提高临床诊疗水平,为患者提供更优质的服务。

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1、 广东省自然科学基金项目(2020A1515011364)。
This work was supported by the Natural Science Foundation of Guangdong Province (2020A1515011364).()
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