【作者】 杨军华；

【导师】 张新平；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2006， 硕士

【摘要】 目的:农村地区不合理用药现象已经引起了全社会的广泛关注,为遏制我国农村地区不合理用药现象,减少不合理用药所带来的健康损害和资源浪费,不少地区已经开展了干预研究,并已出现了一些有益的措施和经验,本研究正是在总结我国农村地区尤其是卫生Ⅷ项目地区的诸多有益经验的基础上,借鉴国际合理用药干预的经验,为制定我国农村合理用药政策策略,促进合理用药政策的有效实施和可持续发展提供依据,并为最终在我国农村地区建立合理用药的可持续发展机制提出政策建议。资料与方法:本研究综合采用文献法、现场调查法、专家法、统计学方法等多种方法进行研究,收集的资料包括:(1)国内外合理用药研究文献资料;(2)卫生Ⅷ项目县调查资料,包括:卫生Ⅷ项目县卫生局、医疗机构用药管理的办法、文件、汇报材料;卫生Ⅷ项目地区21个乡镇的31名人员访谈资料,包括卫生局行政管理人员、医院行政管理人员、医务人员;卫生Ⅷ项目地区乡镇卫生院基本情况、药品管理基本情况;卫生Ⅷ项目地区乡镇卫生院处方资料。(3)新型农村合作医疗试点省调查资料:某新型农村合作医疗试点省(该省要求省名予以保密)4个合作医疗试点县合理用药干预措施实施情况,8个乡级医疗机构2003年至2005年所有阑尾炎患者的住院病历。研究内容包括:(1)我国农村地区常用合理用药评价指标值研究;(2)农村地区合理用药干预措施的效果评价;(3)合理用药干预措施实施策略研究。结果与结论:1、通过对我国近年来发表的农村地区合理用药评价研究文献的查阅、汇总,使用统计学方法计算指标使用频数、最大值、最小值、中位数,发现我国农村地区合理用药评价研究中采用的常见指标是:平均处方用药数、平均处方费用(元)、抗生素处方比例(%)、抗生素占总药物数比例(%)、激素处方比例(%)、注射处方比例(%)等六个处方指标。在现有情况下,激素处方比例等指标值越少越好,基本药物比例值越多越好。本研究参照国际合理用药专家推荐的指标理想值,把各常用指标的最小值(或最大值)与均数(或中位数)之间的范围作为较理想的参考值供国内合理用药研究者参考,平均处方用药数、平均处方费用(元)、抗生素处方比例(%)、抗生素占总药物数比例(%)、激素处方比例(%)、注射处方比例(%)、处方基本药物比例(%)的参考值依次为1.77-3.875、4.86-11.46、22.97%-48.14%、18.32%-25.22%、0%-9.95%、1.86%-43.3%、62.83%-74.22%。2、被调查农村地区采取的以临床诊疗规范和基本药物目录为主的合理用药干预措施已经取得了一定的效果,被调查地区平均处方用药数在2.72到4.54之间,抗生素使用比例在21.27%到31.87%之间,激素处方的比例在6.20%到50%之间,针剂使用比例在11.29%到99.02%之间,处方药物非专利名使用比例在88.71%到99.33%之间,基本药物使用比例在72.37%到98.23%之间,安徽省套餐处方平均费用明显低于非套餐处方平均费用(有显著性差异),合作医疗省合作医疗处方平均费用略低于非合作医疗处方平均费用(无显著性差异)。总体上来说,各省干预组和对照组相比,平均处方用药数、抗生素占总药物数比例、激素处方比例、针剂使用比例有一定程度的下降,基本药物使用比例有一定程度上升。但合作医疗省抗生素使用有加重的倾向,各地激素滥用的状况也未能从根本上改变。项目实施后,卫生Ⅷ项目地区76.88%的被调查对象具有了正确的用药观念,85.95%的被调查对象掌握了合理用药知识,73.42%的被调查对象认为更加注重合理用药管理和合理处方行为,医务人员的用药观念、知识、行为渐趋合理。3、各地区之间干预效果存在一定的差异。实施套餐处方的地区干预组较对照组处方值更为合理(均有显著性差异),且变化幅度大于其他省份,各地之间措施的效果强度存在差别。4、全国农村居民两周未就诊率为45.8%,应住院未住院比例为30.3%,我国农村地区存在普遍的卫生服务利用不足,且有药品利用不足的可能,农村合理用药评价研究者对农村“药品利用不足”问题重视不够。5、单一的处方指标评价合理用药干预措施效果存在一定的弊端,需构建包含观念、知识、行为改变在内的全面的合理用药干预措施效果评价指标体系。6、引起农村地区不合理用药的原因是多方面的,包括:医务人员知识水平低下、政府投入不足、医疗机构过度商业化、医疗保障制度缺乏、虚假药品广告宣传、患者不正确诱导、药品价格秩序混乱等。7、新型农村合作医疗制度与合理用药政策之间存在着相互制约、相互促进的关系,可以相互结合。建议:为进一步促进农村地区合理用药,完善农村地区合理用药研究,建议:1、重视乡镇卫生院院长在促进合理用药中的作用,充分发挥其示范、带动作用;2、实施以临床诊疗规范、基本药物目录为主的十条核心干预措施,具体包括:实施临床诊疗规范、实施基本药物手册、建立医院药事管理机构,完善相关职能、开展医务人员培训、开展用药督导和审核、建立独立的药物信息提供体系、开展药物的公共教育、经济措施、保证政府投入以提高用药和医务人员的工作效率;3、利用实施新型农村合作医疗制度的压力机制,综合使用多种措施协同促进合理用药;4、多部门协作共同促进农村地区合理用药,由合作医疗和医疗救助等保障制度管理部门、财政部门、卫生行政部门、药品监管部门、工商行政部门、物价部门、媒体等共同参与,各司其责,共同促进农村地区合理用药;5、在合理用药评价研究中应密切注意农村地区药品利用不足问题,建立正确的评价假设;6、构建适合我国国情的完善的合理用药干预措施效果评价指标体系,加强标准值研究。建议结构指标主要是对医疗卫生机构药品管理情况进行评价;过程指标主要是对医务人员知、信、行方面进行评价;结果指标主要是处方指标、病人关怀指标和经济指标,对处方行为结果进行评价。本研究的创新之处在于对我国农村地区常用评价指标进行了总结,提出了部分指标的参考值,供我国农村合理用药评价研究者参考;提出了农村卫生服务利用不足条件下的合理用药评价研究中应注意“药品利用不足”问题;初步构建了包含处方指标、观念知识行为转变指标在内的合理用药干预措施效果评价指标体系;对我国农村地区出现的有效干预措施进行了总结,提出了进一步促进农村地区合理用药的十条核心措施和有关政策建议。更多还原

【Abstract】 Object:More and more people pay attention to irrational use of drugs in rural areas. In order to eliminate it and reduce unnecessary waste of medicine resource, we have done many intervention researches. There are many effective interventions and useful experience. This study summarized the experience in rural areas, especially in Health 8 project areas. This study provided some suggestions on how to improve rational use of drugs in rural areas and ensure the ration use of drugs (RUD) policy be effective in a sustainable way.Data and Methods:Literature review, field investigation, expert consultation and statistical method were used in this study. The data included: (1) literatures of rational use of drugs in home and abroad. (2) the data of Health 8 experimental counties, including: documents, reports of Health 8 experimental counties; interview data of 31 person of 21 Health 8 experimental counties, including managers in health management department and health facilities and health workers; data of drug management in health facilities in rural townships; prescription data in health facilities.(3) the data of New-type rural cooperative medical system (CMS) experimental province, including the data of interventions in the province and inpatient medical record of Appendicitis of 8 health facilities in 4 project counties from 2003 to 2005.This study content included: (1) study on values of common evaluation indicators of RUD in rural areas, (2) evaluation of the effect of interventions in investigated areas, (3) study on strategies to apply interventions.Results and Conclusions:1. By reviewing and summarizing the literatures, analyzing the frequency, min, max, mean and median of every indicator, the researcher found common indicators used by researchers were average number of drugs per encounter, average expenditure per encounter, percentage of encounters with an antibiotic prescribed, percentage of antibiotics, percentage of encounters with cortex hormone prescribed, percentage of encounters with an injection prescribed. They are all prescribing indicators. The value of percentage of encounters with cortex hormone prescribed should be lower in China. The value of percentage of essential drugs should be higher in China. Reference values were calculated by referring the optimal value suggested by international expert and the range between min (or max) and mean (or median).Reference values were 1.77-3.875, 4.86%-11.46%, 22.97%-48.14%, 18.32%-25.22%, 0%-9.95%, 1.86%-43.3%. Percentage of essential drugs was 62.83%-74.22%.2. Interventions in investigated areas have some rational effect, such us standard treatment guideline (STG), essential drug list (EDL). Average number of drugs per encounter was 2.72-4.54, percentage of antibiotics was 21.27%-31.87%, percentage of encounters with cortex hormone prescribed was 6.20%-50%, percentage of injections was 11.29%-99.02%, percentage of drugs prescribed by generic name was 88.71%-99.33%, percentage of essential drugs was 72.37%-98.23%. Average expenditure of intervention group was lower than contrast group in Anhui province. Average expenditure of intervention group was a little lower than contrast group in CMS province. Average number of drugs per encounter, percentage of antibiotics , percentage of encounters with cortex hormone prescribed,percentage of injections of intervention groups was lower than contrast groups. But the use of antibiotics was aggravating in CMS areas. The abuse of cortex hormone was not been controlled. Health workers in Health 8 areas have much rational change in concept, knowledge, and behavior on use of drugs. 76.88 percent of investigated people have rational concept, 85.95 percent of investigated have rational knowledge and 73.42 percent of investigated pay more attention to RUD.3. There was much difference in different areas. The intervention group was more rational than the contrast group in AnHui province. It was more rational than other areas.4. The Two-week Non-visit Rate of outpatient service of rural people was 45.8% in China. The Non-visit Rate of inpatient service of rural people was 30.3% in China. People in rural areas make use of health service insufficiently, and may make use of drugs insufficiently. But researchers in our country do not pay attention to this problem.5. Evaluating the effect of interventions by prescribing indicators alone is not appropriate. We must develop all-round indicators including concept, knowledge and behavior change.6. The cause of irrational use of drugs in rural areas is complex, including health workers’poor knowledge, insufficient budget, appropriate health facility commercialization, insufficient health insurance, fake drug advertisement, patient’s improper inducement, improper drug price, etal.7. The relation between new-type rural cooperative medical system and RUD policy is interactive. We can mak use of the combination of two policy.Suggestions:In order to improve RUD in rural areas of China and RUD researches, the researcher suggested:1.Pay more attention to the manager’s impact on improving RUD and make use of its paradigm and leading impact.2.Apply ten core interventions including STG and EDL. They are applying STG, applying EDL, developing a drug management department and perfecting its function, educating health workers, supervising and checking up the use of drugs, developing independent drug information system, carrying out public education, economic interventions, improving the work rate of drug use and health workers by ensuring sufficient budget.3. Make use the pressure of applying the new-type CMS and apply many types of interventions to improve RUD in rural areas.4. Many departments improve RUD cooperatively, including: management department of CMS and MA, health department, department of drug administration, department of industrial and commercial administration, commodity price department and media department.5. Pay attention to the problem of insufficient use of drugs in rural areas, develop valid evaluation hypothesis.6. Constitute proper evaluation indicators of impact on interventions and study standard values. Structural indicators are used to evaluate the drug management in health facilities, process indicators are used to evaluate concept, knowledge and behavior change; outcome indicators are used to evaluate the behavior outcome include prescribing indicators, patient care indicators and economic indicators.更多还原