安徽省三级医院临床用药趋势分析及合理用药策略研究

发布时间：2018-01-13 20:42

本文关键词：安徽省三级医院临床用药趋势分析及合理用药策略研究　出处：《安徽医科大学》2015年硕士论文　论文类型：学位论文

【摘要】：构建药品供应保障体系,促进临床合理用药一直是我国深化医改的重要工作之一。我国曾采用的药品加成政策是医疗机构中药品价格形成的主要方法,曾经对保障医疗机构正常运行发挥了非常重要的作用。但是近些年来,这项政策诱发了医疗机构,特别是个别的医务人员在医疗活动中开大处方、开贵药的情况,给患者增加了经济负担,尤其对临床合理用药和药品供应保障产生不良影响。在我国新一轮医药卫生体制改革中,取消药品加成、斩断医药利益链成为亟待解决的重要问题。三级综合性公立医院改革目前是我国深化医改的重要工作领域,尤其是目前安徽省以推进公立医院转换运行机制为核心,实行取消药品加成、调整医疗服务价格、实施药品带量采购“三同步”的改革过程中,摸清三级综合医院药品使用的现况,对顺利实施综合性公立医院改革,构建适应改革需要的绩效评价体系均有重要参考意义。为了使调研结果具有更好的代表性,本课题以安徽省三级综合性公立医院为调查对象,根据安徽省不同地区以及经济发展的特点,采用分层随机抽样调查方法,共抽样5个地区三级医疗机构,对5家医院在医改前后分别2008年、2013年的所有药品消耗情况进行分析。从药品可获得性、可负担性、合理用药三个维度,经文献调研选用医改效果评估的核心指标及合理用药调查指标体系,采用药物利用研究方法对我省三级综合医院药物使用的情况进行评价,探讨医改实施过程中安徽省三级公立医院药物使用可能存在的问题,在安徽省医改新形势下,为促进临床合理用药、构建完善的药品供应保障体系提供政策建议。主要内容概括如下：1.安徽省三级公立医院医疗机构药品使用的总体构成收集5家三级医院2008年1月1日至12月31日、2013年1月1日至12月31日前后两年使用的药品数据,分别计算以下指标。1.1药品使用金额分析计算2008年、2013年所有品种药品使用的总金额,可以用于比较不同地区的药品资源消耗水平。同时按照销售金额进行排序,得出排名前20位的药品品种。结果显示,2008年金额排序前十的药品为：神经节苷脂钠、奥美拉唑钠、头孢孟多、头孢替安、头孢甲肟、重组人白细胞介素-Ⅱ、奥拉西坦、左氧氟沙星、头孢吡肟、头孢西丁；2013年金额排序前十的药品为：神经节苷脂钠、奥拉西坦、头孢替安、泮托拉唑、多西他赛、甲磺酸伊马替尼、小牛血清去蛋白、头孢西丁钠、艾迪、复合辅酶。1.2用药频度(DDDs)分析计算2008年、2013年所有品种药品使用的DDDs值,结果显示,2008年DDDs排序前十的药品为：维生素C注射液、单硝酸异山梨酯、维生素C片、曲美布汀、克拉霉素、头孢克肟、尼群地平、左西替利嗪、厄贝沙坦、伊曲康唑；2013年DDDs排序前十的药品为：维生素C注射液、氨氯地平、硝苯地平、维D钙、凝血酶、单硝酸异山梨酯、雷公藤多苷、地高辛、白芍总苷、利可君。2.安徽省三级公立医院医疗机构药品使用的分类构成在分析所有药品总体构成的基础上,按照药理作用分类,分别研究两个年度各类药品的使用金额和药品用药频度构成情况,更为具体地探讨临床各类药品使用可能存在的不合理现象。2.1抗微生物类药品使用金额及用药频度分析2013年较2008年抗微生物药使用金额及用药频度均小幅增长(分别为32.03%和13.94%),远较药品总使用金额及总用药频度增长幅度小(分别为212.99%和81.47%)。2013年的抗微生物类药品中碳青霉烯类、糖肽类大分子抗菌药使用金额进入排名前20位。相较与2008年,2013年的氨基糖苷类抗菌药物使用频度排名跌出前20名,大环内脂类使用频度有所增加。2.2神经系统用药药品使用金额及用药频度分析2013年较2008年神经系统用药金额及使用频度均出现大幅增长(分别为323.76%和136.27%)。用药金额增长幅度远大于使用频度增长幅度,说明神经系统用药以价格较为昂贵的药品增长为主。2013年营养脑神经药物取代调节脑血流、脑代谢药物成为神经系统用药金额中占比最大类,但使用频度中调节脑血流、脑代谢类药物仍占神经系统用药最大比例。2008年及2013年两年使用金额最大的药品均为单唾液酸四己糖神经节苷脂。2.3消化系统用药药品使用金额及用药频度分析2013年较2008年消化系统用药金额及使用频度均有较大增长(分别为249.94%和76.24%)。2008年及2013年消化系统用药金额排名前20位均为抑酸药和肝胆胰疾病用药,2013年抑酸药使用金额占比相对下降,但2013年抑酸药使用频度却相对上升。2.4循环系统用药药品使用金额及用药频度分析2013年较2008年循环系统用药金额及用药频度均有增长(分别为268.35%和181.15%)。2013年相较于2008年抗心绞痛、扩血管药物使用金额及使用频度占比均有下降,利尿药使用金额占比2013年未进入排名前20位。2008年及2013年循环系统药品使用频度排名中抗高血压药及抗心绞痛、扩血管药均位于前列,2013年抗心绞痛、扩血管药用药频度占比下降。胺碘酮等抗心律失常药未进入使用金额及使用频度排名前20位。抗高血压药有使用种类相对集中趋势。2.5激素类药品使用金额及用药频度分析2013年较2008年激素类药品金额及用药频度均出现增长(分别为189.97%和160.21%)。使用金额与用药频度增长幅度相接近,说明激素类药品的增长以使用频度的增长为主。胰岛素类为激素类药品中使用金额最大类。2.6营养类药品使用金额及用药频度分析2013年较2008年营养类药品使用金额及用药频度均出现增长(分别为187.62%和46.41%)。2008年及2013年两年肠内营养药品使用金额均占比很低,2013年占比进一步下降。肠外营养中脂肪乳、氨基酸使用金额占比两年均居于首位,2013年电解质、微量元素类药品出现较大增幅。使用频度排名中肠内营养药2013年进入排名前20位,电解质、微量元素类药使用频度占比也出现较大增长。转化糖电解质在其他相似研究中并未出现在使用金额排名前列中,但在本次调查中2008年及2013年两年均出现在使用金额前列中。2.7中成药药品使用金额及用药频度分析2013年较2008年中成药用药金额及用药频度均有增加(分别为231.60%和142.27%)。两年中成药使用金额排名中辅助抗肿瘤药均占比最多。2013年及2008年中成药使用频度排名中位于首位的均为活血化瘀类中成药。说明辅助抗肿瘤药价格相对较高。本次调查中抗肿瘤中成药位居前列的几种药品与其他类似研究结果基本一致。2.8抗肿瘤类药品使用金额及用药频度分析2013年较2008年抗肿瘤药使用金额及使用频度均出现飞速发展(分别为1053.64%和561.81%)。抗肿瘤靶向药物在本次调查中使用金额得到巨大增长,原因主要为安徽省发病率的增长及抗肿瘤靶向药物在临床使用越来越多且其价格非常昂贵。3.2008年与2013年药品使用变化分析从药品使用金额来看,只有抗菌药物的使用金额相对于总金额未取得增长,其他类型药品均取得较大增长,其中又以抗肿瘤药物、神经系统药物增长较快。大部分的药物增长有合理解释,但部分药品如转化糖电解质存在不合理的快速增长现象。从药品使用频度来看,抗菌药物、中成药、神经系统药物及消化系统药物相对于总DDDs的增长幅度未取得增长,其他类型药物均取得使用频度的增长,其中又以抗肿瘤用药频度增长幅度最大。综合两者可以看到只有抗菌药物在使用金额及使用频度上相对于总金额及总使用频度均出现大幅下降,其他类型药物未见此现象,说明抗菌药物的临床滥用现象正在得到控制。而抗肿瘤药无论药物使用金额或使用频度的增长均居于各种药品之首,这与抗肿瘤药物2008年的基数较小及近年的快速增长有关。从中成药(使用金额增长231.60%,DDDs增长142.27%)及神经系统药物(使用金额增长323.76%,DDDs增长136.27%)的使用金额大幅上涨,而DDDs增长较少可以推断出此两类药品使用金额的增长主要以高价格药品增长为主或使用药品种类相对集中引起或使用药品种类相对集中引起或使用药品种类相对集中引起。
[Abstract]:The construction of drug supply security system, promote the clinical rational use of drugs is one of the important work of China's deepening reform. Our country has adopted the drug addition policy is the main method of drug price formation in medical institutions, to ensure the normal operation of medical institutions have played a very important role. But in recent years, the policy induced the medical institutions, especially other medical personnel prescription in medical activities, expensive drugs, increased economic burden to patients, especially on the adverse effects of clinical medication and drug supply security. In the new round of China's medical and health system reform, cancel the drug addition, cut pharmaceutical interests the chain has become an important problem to be solved. Three comprehensive reform of public hospitals is an important field in China deepening reform, especially in Anhui province to promote public hospital conversion operations As the core mechanism, the implementation of cancel the drug addition, adjusting the price of medical services, the implementation of drug procurement with the amount of "three simultaneous" in the process of reform, the status of drug use in three general hospitals to find out, for the smooth implementation of the comprehensive reform of public hospitals, to construct a performance evaluation system has important reference significance. In order to represent the needs of the reform the research results is better, subject to the Anhui Province three comprehensive public hospitals as the research object, according to the characteristics of different areas of Anhui province and the economic development, using stratified random sampling method, a total sample of 5 regions of the three level medical institutions of 5 hospitals in the health care reform respectively before and after 2008, analyze all drug consumption in 2013. From the drug availability, affordability, three dimensions of rational use of drugs, the literature research selection of core indicators to assess the effect of health care and medication adjustment Check the index system, using the method of drug utilization research situation of drug use in three grade hospitals to my evaluation of possible problems in Anhui Province three public hospitals in the study of drug reform implementation process, in Anhui province reform under the new situation, to promote the clinical rational use of drugs, and provide policy suggestions to construct perfect drug supply security system the main contents are as follows: 1. the overall Anhui Province three public hospitals, medical institutions of drug use in three hospitals from 5 of January 1, 2008 to December 31st, January 1, 2013 to December 31st using the drug data two years before and after 2008, calculation and analysis of the following indicators.1.1 drug use amount were calculated, in 2013 the total amount of all varieties of drug use, can to compare the different parts of the drug level of resource consumption. At the same time are sorted according to the amount of sales, it ranked the top 20. The types of drugs. The results showed that the amount of 2008 top ten drugs: ganglioside sodium, omeprazole sodium, cefamandole, cefotiam, cefmenoxime, recombinant human interleukin-2, oxiracetam, levofloxacin, cefepime and cefoxitin; in 2013 the amount of sort ten drugs: ganglion GM1, oxiracetam, cefotiam, pantoprazole, docetaxel, imatinib mesylate and bovine serum protein, cefoxitin sodium, Addie, compound coenzyme.1.2 (DDDs) analysis DDDs in 2008 2013, all varieties of drug use DDDs value showed that the 2008 DDDs top ten drugs for vitamin C injection, isosorbide mononitrate, vitamin C tablets, Cu Mei Bbu Dean, clarithromycin, cefixime, nitrendipine, levocetirizine, irbesartan, itraconazole; 2013 DDDs top ten drugs:. C injection, amlodipine, nifedipine, vitamin D, calcium, thrombin, isosorbide mononitrate, digoxin, tripterygium glycosides, total glucosides of paeony, Leucogen.2. classification in Anhui Province three public hospitals, medical institutions of drug use in analysis of all drugs on the basis of the overall composition, in accordance with the classification of pharmacological effects. The composition of the two annual all kinds of drugs were used and the amount of drug use frequency, more specifically to investigate all kinds of clinical drug use unreasonable phenomenon may exist.2.1 antimicrobial drug use amount and DDDs of anti microbial drugs in 2013 compared to 2008 using amount and DDDs increased slightly (respectively 32.03% and 13.94%), is far more than the total drug use amount and DDDs growth (212.99% and 81.47%).2013 years of anti microbial drugs in carbapenem, glycopeptide antimicrobial molecules The amount of drug use in the top 20. Compared with 2008, 2013 aminoglycoside antibiotic use frequency ranking fell out of the top 20, use frequency of lipid ring increased.2.2 nervous system drugs drug use amount and DDDs analysis in 2013 compared to 2008 the nervous system drug amount and use frequency of both increased significantly (respectively 323.76% and 136.27%). The growth rate is far greater than the amount of drug use frequency increase, indicating to nervous system drugs more expensive drugs increase.2013 years brain nutrition drugs to replace the regulation of cerebral blood flow, cerebral metabolism drugs accounted for than the maximum amount of medication in the nervous system, but the frequency of use in the regulation of cerebral blood flow, brain the metabolism of drugs still accounted for the largest proportion of nervous system drugs.2008 and 2013 two years with the largest amount of drugs are monosialo four hexose ganglioside .2.3 digestive system drugs drug use amount and DDDs analysis in 2013 compared with 2008 amount and frequency of use of digestive system drugs have significant growth (249.94% and 76.24%).2008 medication and 2013 digestive system the amount of the top 20 are acid suppressive drugs and hepatobiliary disease medication, 2013 using the amount of acid inhibitory drugs accounted for the relative decline but in 2013, acid suppression drugs use frequency is relatively increased.2.4 circulatory system drugs drug use amount and DDDs analysis in 2013 compared with 2008 circulation amount of drugs and DDDs increased (268.35% and 181.15%).2013 year compared to 2008, anti angina, vasodilator drug use amount and use frequency have accounted for the decline, diuresis the amount of drug use accounted for 2013 did not enter the top 20.2008 and 2013 circulation system of antihypertensive drugs in drug frequency ranking and anti angina Use Pain, vasodilators are at the forefront of 2013, anti angina, vasodilator DDDs proportion decreased. Such as amiodarone antiarrhythmic drug use did not enter the amount and frequency of use of the top 20 antihypertensive drugs. The relative concentration trend of.2.5 hormone drugs use amount and DDDs analysis in 2013 compared with 2008 hormone drugs the amount and frequency of drug use types have increased (189.97% and 160.21%). The use amount and DDDs of the growth rate is close to that of growth hormone drugs to increase insulin use frequency. For hormone drugs used in the largest amount of.2.6 nutrition drugs use amount and DDDs analysis in 2013 than in 2008 nutrition drugs use amount and DDDs increased (187.62% and 46.41%) of.2008 and 2013 two years of enteral nutrition drug use amount accounted for more than Very low in 2013, a further decline in the proportion of fat emulsion. Parenteral nutrition, amino acid usage amount accounted for more than two years in the first place, 2013 electrolyte, trace elements of drugs appear larger increase. The frequency of use of enteral nutritional medicine in 2013 ranked the top 20, electrolyte, frequency ratio also grew larger use of trace element medicine. Invert sugar and electrolytes in other similar study did not appear in the use of the amount of ranking, but in 2008 the survey in 2013 and two years appeared in the forefront in the.2.7 using the amount of proprietary Chinese medicines use amount and DDDs in 2013 compared with 2008 analysis of Chinese patent medicine amount and DDDs increased (231.60% and 142.27%). Two years of traditional Chinese medicine using the ranking in the amount of auxiliary antitumor drugs are accounted for up to.2013 and 2008 Chinese medicine use frequency ranking the top are live The blood stasis medicine. Auxiliary antitumor drug price is relatively high. This investigation in several antitumor medicine drugs forefront and other similar research results of.2.8 antitumor drugs using amount and DDDs analysis in 2013 compared with 2008 anti tumor drug use amount and frequency of use are the rapid development (1053.64% 561.81%). Anti tumor drug targeting in this investigation using the amount of gains, the main reason for the incidence of Anhui province and the growth of tumor targeting drugs in clinical use more and more and the price is very expensive.3.2008 and 2013 drug use change analysis from the point of view of the amount of antimicrobial drug use, only using the amount of drugs relative to the total amount without growth, other types of drugs have achieved greater growth, among which the anti-tumor drugs, nervous system drugs increased Most of the drugs have increased quickly. A reasonable explanation, but some drugs such as invert sugar and electrolytes of the rapid growth of the phenomenon of irrational drug use frequency. From the point of view, antibacterial drugs, medicine, drug nervous system drugs and digestive system compared to the total DDDs growth rate did not achieve growth, other types of drugs were made using frequency of growth, including the largest increase in DDDs of anti tumor. Combination of which can be seen only in the use of antibacterial drugs amount and use frequency relative to the total amount and the total DDDs fell sharply, this phenomenon was not found in other types of drugs, antibiotics abuse that clinical phenomenon is under control. But the growth of antitumor drugs amount or frequency of use both drug use in the drug for the first time, this small base with anti tumor drugs in 2008 and the rapid growth in recent years. From Traditional Chinese medicine (using the amount of growth of 231.60%, DDDs growth of 142.27%) and nervous system drugs (using the amount of growth of 323.76%, DDDs growth 136.27%) use amount rose sharply, while DDDs grew less can infer the two types of drug use amount of the main growth by the high price of drugs or drug use growth or drug use caused by the relative concentration of species the relative concentration of species caused by drug types or the use of the relative concentration of lead.

【学位授予单位】：安徽医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R969.3

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