本文選題：白內(nèi)障 + 手術(shù)��； 參考：《第三軍醫(yī)大學》2011年博士論文

【摘要】：背景 白內(nèi)障為全球致盲眼病的主要原因。在我國約有250萬人因白內(nèi)障致盲,占全球白內(nèi)障致盲總數(shù)的10%。隨著人口的老齡化,預計我國每年新增白內(nèi)障患者將超過100萬,而我國的白內(nèi)障年手術(shù)量尚不足以解決每年的新增例數(shù)。因此,我國的白內(nèi)障盲防治問題十分嚴峻。1999年世界衛(wèi)生組織(WHO)指出當時(1999年)我國白內(nèi)障手術(shù)率(cataract surgery rate, CSR)在百萬人口中僅有270例,僅比非洲的CSR(200例)略多,而發(fā)達國家的CSR為3000～5000例,印度為3100例,東歐國家CSR為800～3000例。近年來,我國在“視覺第一中國行動”及“視覺2020,享有看得見的權(quán)利”行動的推動下,在中國殘聯(lián)、衛(wèi)生部及國內(nèi)外非政府組織的領導及支持下,CSR明顯提高,2004年達到448.7例。但與發(fā)達國家相比,仍存在巨大差距,就連和我們經(jīng)濟及人口相當?shù)挠《认啾?差距也非常顯著。而且,同年重慶市的CSR卻只有217.4例,不及全國平均水平的一半,排名倒數(shù)第二。重慶作為中國最年輕的直轄市,其CSR卻如此低下是值得深思的一個重要問題。 盡管政府通過大量的工作,如:提供部分補助、慈善機構(gòu)免費手術(shù)等以求改變這種CSR低下的狀況,由于需要手術(shù)治療的患者量太大,且并非每位患者都能享受到這種福利待遇,白內(nèi)障盲防治工作任重道遠。2003年,政府決定全面實施醫(yī)改,為廣大群眾提供基本醫(yī)療服務。那么,作為我國政府做出承諾并積極參與“視覺2020,享有看得見的權(quán)利”這一全球性防盲治盲目標中的首要任務——白內(nèi)障盲的防治,醫(yī)改對其是否產(chǎn)生影響?又會產(chǎn)生怎樣的影響?目前尚未見相關(guān)文獻報道。 近年來,國家的白內(nèi)障盲防治重點在于農(nóng)村患者,這極大的促進了農(nóng)村白內(nèi)障盲的防治工作,但在臨床工作中,我們發(fā)現(xiàn)有相當多重慶城鎮(zhèn)老年性白內(nèi)障患者在白內(nèi)障成熟期、甚至過熟期視力極差的情況下,仍未接受手術(shù)治療,究其原因并非經(jīng)濟困難及醫(yī)療條件的限制。那么,到底是什么原因?qū)е轮貞c城鎮(zhèn)白內(nèi)障患者延遲手術(shù)?隨著農(nóng)村城市化和人口老年化的發(fā)展,將會有越來越多的城鎮(zhèn)白內(nèi)障患者,這部分患者能否及時手術(shù),恢復視功能,也是一個不可忽視的問題。 因此,了解重慶市醫(yī)療機構(gòu)白內(nèi)障手術(shù)現(xiàn)狀和相關(guān)影響因素,對加快重慶的白內(nèi)障盲防治進程具有重要意義。 目的 在調(diào)查2003-2008年間重慶主城區(qū)醫(yī)院年齡相關(guān)性白內(nèi)障手術(shù)現(xiàn)狀及分析相關(guān)影響因素的基礎上,了解醫(yī)療體制改革對重慶市年齡相關(guān)性白內(nèi)障手術(shù)的影響,并分析重慶城鎮(zhèn)年齡相關(guān)性白內(nèi)障患者延遲手術(shù)的原因,以期為加快重慶白內(nèi)障盲防治工作提供借鑒和參考。 研究對象與方法 1.樣本來源:采用多級整群抽樣從重慶主城9區(qū)中隨機抽取6區(qū),在此6區(qū)中再隨機抽取其內(nèi)所轄的8所醫(yī)院,即:第三軍醫(yī)大學大坪醫(yī)院、重慶醫(yī)科大學附屬第二醫(yī)院、武警重慶總隊醫(yī)院、重慶市第三人民醫(yī)院及重慶江北區(qū)第一人民醫(yī)院、重慶沙坪壩區(qū)第一人民醫(yī)院、重鋼總醫(yī)院、重慶建設廠職工醫(yī)院,進行研究。 2.資料收集和分析: ⑴.收集上述8所醫(yī)院中于2003年1月1日至2008年12月31日因年齡相關(guān)性白內(nèi)障而接受手術(shù)治療的所有病例,回顧分析患者一般情況(來源、性別、年齡、術(shù)前最佳矯正視力、晶狀體核硬度、是否享有醫(yī)療保險)以及手術(shù)量、患者所選用手術(shù)方式、所選用人工晶狀體的類型、醫(yī)師一期人工晶體植入率等指標,了解重慶市白內(nèi)障手術(shù)現(xiàn)狀和相關(guān)影響因素。 ⑵.收集上述8所醫(yī)院中于2003年1月1日至2008年12月31日因年齡相關(guān)性白內(nèi)障而接受手術(shù)治療的所有重慶籍患者手術(shù)量、所選用的手術(shù)方式、所選用的人工晶狀體和享受醫(yī)療保險情況,分析醫(yī)療體制改革對白內(nèi)障手術(shù)量、手術(shù)方式、所選用人工晶狀體的影響。 ⑶.通過對自2008年1月1日至2008年12月31日間于上述八所醫(yī)院在白內(nèi)障成熟期及過熟期時方行手術(shù)(即延遲手術(shù))的重慶城鎮(zhèn)患者進行問卷調(diào)查,了解患者延遲手術(shù)的原因。 結(jié)果 1. 2003-2008年間重慶市主城區(qū)醫(yī)院白內(nèi)障手術(shù)現(xiàn)狀: ⑴.手術(shù)量逐年增加,以城鎮(zhèn)患者為主,但農(nóng)村患者所占比例逐年提高; ⑵.患者接受手術(shù)的時間逐漸提前,表現(xiàn)為接受手術(shù)的年齡呈年輕化趨勢,接受手術(shù)時最佳視力逐漸增高,晶狀體核硬度逐漸降低; ⑶.超聲乳化白內(nèi)障吸除術(shù)已成為患者接受白內(nèi)障手術(shù)的主要術(shù)式; ⑷.人工晶狀體的選擇以非折疊型為主,但折疊人工晶狀體的比例逐年增加;⑸.白內(nèi)障醫(yī)生一期人工晶狀體植入率明顯提高。 2.醫(yī)療體制改革對重慶籍年齡相關(guān)性白內(nèi)障患者手術(shù)的影響: (1)醫(yī)療體制改革對白內(nèi)障手術(shù)量的影響:2003-2008年間,主城區(qū)醫(yī)院白內(nèi)障手術(shù)量逐年增加,享有醫(yī)療保險患者手術(shù)量亦逐年增加,二者呈高度正相關(guān)性(r=0.971, p=0.0010.05)。 (2)醫(yī)療體制改革對白內(nèi)障患者選擇手術(shù)方式的影響:2003-2008年間,主城區(qū)醫(yī)院選擇超聲乳化白內(nèi)障手術(shù)方式的手術(shù)量逐年增加,享有醫(yī)療保險患者手術(shù)量亦逐年增加,二者呈高度正相關(guān)性(r=0.985,P=0.0000.05)。享有醫(yī)療保險的患者選擇超聲乳化白內(nèi)障的比例明顯高于未享有醫(yī)療保險的患者(p0.001)。 (3)醫(yī)療體制改革對白內(nèi)障患者選擇人工晶狀體的影響:2003-2008年間,主城區(qū)醫(yī)院白內(nèi)障患者選擇折疊人工晶狀體的量逐年增加,享有醫(yī)療保險患者手術(shù)量亦逐年增加,二者呈高度正相關(guān)性(r=0.984,P=0.0000.05)。享有醫(yī)療保險的患者選擇折疊人工晶狀體的比例明顯高于未享有醫(yī)療保險的患者(p0.001)。 3.重慶城鎮(zhèn)年齡相關(guān)性白內(nèi)障患者延遲手術(shù)的問卷調(diào)查:對于重慶城鎮(zhèn)患者而言,經(jīng)濟因素不是延遲手術(shù)的主要原因,而“認為白內(nèi)障不成熟不能手術(shù)”、“因尚能視物而暫不愿行白內(nèi)障手術(shù)”、“不知道自己患白內(nèi)障”分別為延遲手術(shù)的三大原因;延遲手術(shù)的時間與患者的年齡,是否享有醫(yī)療保險及是否每年進行眼科體檢有關(guān)(p0.05)。 結(jié)論 1. 2003-2008年間,重慶市主城區(qū)醫(yī)院年齡相關(guān)性白內(nèi)障手術(shù)量逐年增加,農(nóng)村患者所占比例明顯提高;白內(nèi)障患者,尤為城鎮(zhèn)患者,對視覺質(zhì)量的要求逐年提高;白內(nèi)障醫(yī)生的手術(shù)技能明顯提高。這與6年來重慶市國民經(jīng)濟快速發(fā)展、醫(yī)改不斷完善、醫(yī)療條件的改善、市民自我防護和眼保健意識有所增強密切相關(guān)。 2.醫(yī)改是影響重慶籍白內(nèi)障患者能否接受手術(shù)、選擇手術(shù)方式和人工晶狀體類型的一個重要因素。參保的患者更易接受手術(shù),選擇更好的超聲乳化手術(shù)方式及折疊人工晶狀體。說明醫(yī)改不僅有利于白內(nèi)障盲防治,還有利于提高白內(nèi)障患者的視覺質(zhì)量。 3.在城鎮(zhèn)患者中延遲手術(shù)治療的時間與患者性別、學歷、年收入無關(guān),而和患者年齡、是否享有醫(yī)療保險、是否參加眼部體檢有關(guān)。對50歲以上人群每年進行眼部體檢,擴大醫(yī)保的覆蓋范圍和支持力度,同時加強白內(nèi)障科普知識宣傳,是加速重慶城鎮(zhèn)白內(nèi)障盲防治工作的重要措施。
[Abstract]:Background

In recent years , China ' s cataract surgery rate ( CSR ) is estimated to be more than 1 million because of cataract blindness , which accounts for 10 % of global cataract blindness .

Although the government has adopted a great deal of work , such as the provision of partial subsidies , the free operation of charities and so on in order to change the state of the low CSR , the government has decided to implement the reform in a comprehensive way and provide basic medical services for the broad masses . In 2003 , the government decided to fully implement the reform and provide basic medical services for the broad masses .

In recent years , the focus of cataract blindness prevention in the country is the rural patient , which greatly promotes the prevention and cure of cataract blindness in rural areas . However , in the clinical work , we have found that there are quite a lot of senile cataract patients in Chongqing .

Therefore , it is very important to understand the present situation of cataract surgery in Chongqing medical institutions and the related factors , and to speed up the cataract blindness prevention and control process in Chongqing .

Purpose

On the basis of investigating the present situation and influencing factors of age - related cataract surgery in Chongqing ' s main urban area between 2003 and 2008 , this paper analyzes the influence of medical system reform on age - related cataract surgery in Chongqing , and analyzes the causes of delayed operation of age - related cataract patients in Chongqing , with a view to providing reference for speeding up the prevention and treatment of cataract blindness in Chongqing .

Research objects and methods

1 . Sample source : A multi - level cluster sampling is adopted to randomly extract 6 districts from 9 districts of Chongqing main city , and 8 hospitals under their jurisdiction are randomly selected in the 6 districts , namely , the Third Military Medical University , the Second Affiliated Hospital of Chongqing Medical University , Chongqing General Hospital of Chongqing Medical University , the Third People ' s Hospital of Chongqing and the First People ' s Hospital in Jiangbei District of Chongqing , the First People ' s Hospital of Shapingba District of Chongqing , the General Hospital of Heavy Steel , and the Staff Hospital of Chongqing Construction Plant .

2 . Data collection and analysis :

( 1 ) Collect all the cases in the above - mentioned eight hospitals from January 1 , 2003 to December 31 , 2008 due to age - related cataract , and review the general situation of the patients ( source , sex , age , preoperative best corrected vision , lens nucleus hardness , whether or not to have medical insurance ) as well as the amount of operation , the mode of operation selected by the patient , the type of the intraocular lens selected , the implantation rate of the first - stage intraocular lens , and the related factors .

( 2 ) To collect the operation amount of all Chongqing patients who received surgery from January 1 , 2003 to December 31 , 2008 due to age - related cataract in the eight hospitals mentioned above , the surgical mode selected , the selected intraocular lens and the medical insurance coverage , and analyze the influence of medical system reform on cataract surgery amount , operation mode , and selected intraocular lens .

( 3 ) To investigate the causes of delayed operation of patients by means of a questionnaire survey of Chongqing urban and town patients from January 1 , 2008 to December 31 , 2008 , during cataract maturity and over - mature period ( i.e . , delayed surgery ) .

Results

1 . Status of cataract surgery in main urban areas of Chongqing during 2003 - 2008 :

( 1 ) The proportion of operation increased year by year , mainly in town patients , but the proportion of rural patients increased year by year ;

( 2 ) The time of the patient receiving the operation gradually advanced , showing that the age of the operation was younger , the best visual acuity was gradually increased at the time of surgery , and the hardness of the nucleus of the lens gradually decreased ;

( 3 ) phacoemulsification with phacoemulsification has become the main surgical procedure for patients with cataract surgery ;

( 4 ) The selection of intraocular lens was the main non - folding type , but the proportion of foldable intraocular lens increased year by year ; ( 5 ) The implantation rate of intraocular lens increased significantly in the first stage of cataract .

2 . Effect of medical system reform on operation of patients with age - related cataract in Chongqing :

( 1 ) The effect of medical system reform on cataract surgery was that in 2003 - 2008 , the operation volume of cataract surgery increased year by year , and the operation volume of patients with medical insurance increased year by year . Both were highly positive ( r = 0.9971 , p = 0.0010 . 05 ) .

( 2 ) The effect of medical system reform on the choice of operation mode of cataract patients : In 2003 - 2008 , the operation volume of choosing phacoemulsification cataract surgery increased year by year , and the operation volume of patients with medical insurance increased year by year . Both were highly positive ( r = 0.985 , P = 0.0000.05 ) . The proportion of patients with medical insurance selected for phacoemulsification was significantly higher than those without medical insurance ( p0.001 ) .

( 3 ) The effect of medical system reform on the choice of intraocular lens in cataract patients : in 2003 - 2008 , the amount of foldable intraocular lens increased year by year , and the operation volume of patients with medical insurance increased year by year , with positive correlation between them ( r = 0.984 , P = 0.0000.05 ) . The proportion of patients who had access to health insurance was significantly higher than those who did not have medical insurance ( p0.001 ) .

3 . Questionnaire of delayed operation of age - related cataract patients in Chongqing : For Chongqing urban patients , economic factors are not the main causes of delay surgery , and " cataract surgery is not considered to be performed in cataract surgery " , " it is not known that cataract surgery " is the three major causes of delayed surgery , and whether the time of delay surgery is related to the age of the patient , whether it is entitled to medical insurance and whether to carry out ophthalmological examination every year ( p . 05 ) .

Conclusion

1 . In the period of 2003 - 2008 , the age - related cataract operation in the main urban areas of Chongqing increased year by year , and the proportion of patients in rural areas was obviously improved ; cataract patients , especially in urban areas , had improved the visual quality ; the operation skills of cataract doctors increased significantly . This was closely related to the rapid development of the national economy in Chongqing in the past six years , the improvement of medical reform , the improvement of medical conditions , the self - protection of the public and the enhancement of eye health awareness .

2 . The medical reform is an important factor which affects the operation , choice of operation mode and the type of intraocular lens in patients with cataract in Chongqing . It is easier to accept the operation and choose the better mode of phacoemulsification and foldable intraocular lens .

3 . The time of delay surgery in urban patients is not related to the patient ' s gender , educational background and annual income , regardless of age of the patient , whether it has medical insurance or whether to take part in the medical examination of the eye . For more than 50 years old , the medical examination should be carried out to enlarge the coverage and support of medical insurance . At the same time , it is an important measure to speed up the prevention and control of cataract blindness in Chongqing .

【學位授予單位】：第三軍醫(yī)大學
【學位級別】：博士
【學位授予年份】：2011
【分類號】：R779.66

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