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Title

基於門診處方分析的中國西部農村醫療機構合理用藥研究

English Abstract

Background The rational use of drugs is a very important issue about human health and disease. However, the use of drugs is actually worrying, for about 1/3 of the patients in the world died as a result of irrational drug use, and more than half of drugs are in unreasonable prescription, preparation and sales. Also, the rational use of drugs in China is not optimistic. For instance, there are about 12% ~ 32% of drugs are used irrationally, especially 50% of antibiotics’ use is unreasonable. There are 2500 thousands people got hospitalized due to drug-induced diseases every year, and about 192 thousands of them died. The irrational drugs use will not only hurt public health, but also cause excessive consumption of medical resources, and an increasing financial burden of patients and society. Irrational drug use in rural areas deserves more attention due to its lack of health resources and backward management systems. Objective This study analysis the outpatient prescriptions in rural health facilities in western China to evaluate the rational drugs use and its possible regional differences there. Also, the factors influence the rational use of drugs will be explored. Further more, this study will put forward suggestions to provide a reference for the rural health policy making in western China. Methods This is a retrospective study that a total of 33729 prescriptions were selected from 7 provinces / autonomous regions (Gansu Province, Guangxi Zhuang Autonomous Region, Guizhou Province, Ningxia Hui Autonomous Region, Sichuan Province, Tibet autonomous region and Xinjiang Uygur Autonomous Region) in western China in 2011. Firstly, 3 sample counties were extracted from each province according to its economic development level (GDP) dividing into good, medium and poor, where the County People’s Hospital, Chinese Medicine Hospital and Maternal and Child Health Hospital in this county were selected. Next, 3 towns were selected in ii each county according to the order of population from large to small, and the township hospitals and 3 village clinics of each town were selected as survey objects. In the sample of 172 hospitals, 15 prescriptions every month in 2011 were selected randomly in each hospital, and totally 30572 available prescriptions were selected. The drug evaluation index of WHO/DAP for developing countries was used to described the rational drugs use. The F test and chi square test were used to analysis the differences of rational drug use in different areas or different levels of medical institutions. The comprehensive evaluation was used to quantitatively describe the overall situation of rational drugs use. The multiple regression and factor analysis were used to analysis of factors influencing rational drugs use. Results Among all the 7 provinces, the average number of drugs per prescription was 3.8. The percentage of prescriptions including antibiotics was 57.3%, which was 140% more than the standard of WHO. The percentage of prescriptions including injections was 33.9%, which was 140% more than the standard. There are regional differences in the rational use of drugs in health facilities at all levels, for example, the percentage of prescriptions including antibiotics of township hospitals in different regions was different ( 2 = 44.847,P = 0.000) . Particularly, the indicators of rational drug use in Xinjiang was more critical than the others, as that the percentage of antibiotics prescriptions there was 77.1%, which was 230% more than the standard, at the same tine, the percentage of injection prescriptions was 47.3%, which was 150% more than the standard. Tibet was more rational than the others in drug using. The scores of comprehensive evaluation of rational drug use in all provinces /autonomous regions shows that the rational drug use score of Guizhou (84.2), Ningxia (76.0) and Tibet (84.2) is better, and Gansu (69.3), Sichuan (62.4) and Guangxi (60.7) in the medium, and Xinjiang (55.8) is poor. iii Prescriptions of Chinese patent medicines accounted for 62.47% of the total prescriptions in rural health facilities, in which the county, township and village hospitals accounted for 49.76%, 56.96% and 71.51% of the total prescriptions, respectively. The number of species of Chinese patent medicines in a prescription in county, township and village hospitals were 1.38, 1.91 and 2.54. The drug costs of every prescription in these health facilities were 52.20 , 21.89 and 19.37 yuan. The level of health facilities has the biggest influence on the prescription cost of rural health facilities, followed by the number of Chinese patent medicines, the use of injections, and the combine with antibacterial drugs. Factors affecting the comprehensive evaluation scores of rational use are the burden factors, prescription factors and the management factors. Conclusion The irrational drug use generally exist in rural health facilities in western China, especially the use of antibiotics and injections. The drug use of different regions is also different, and that irrational drug use in Xinjiang is more serious than in other provinces (autonomous regions). The prescription cost is affected by the level of health facilities. The rational use of drugs is not only affected by prescription factors, but also the payment burden and management factors. The government departments needs to adjust health policy in rural areas to promote rational drug use based on the specific needs and medication characteristics in different regions at all levels of health facilities.

Chinese Abstract

背景:藥品的合理使用關乎人類的健康與疾病,是非常重要的健康議題。 然而藥品的實際使用情況卻讓人擔憂:全球約三分之一的患者由于不合理用藥 而死亡,超過半數的藥品都存在不合理的處方、配製和銷售的情況。我國合理 用藥情況也不容樂觀:約 12% ~ 32%的用藥者存在不合理用藥問題,尤其是抗 菌藥物的使用 50%以上都不合理;每年因藥源性疾病而住院的患者達 250 多萬 人,其中約 19.2 萬人死于用藥不當;近年來因不合理使用中藥和中成藥引发的 不良反應事件逐漸增多。藥品的不合理使用不僅會造成公眾健康損害,還會導 致醫藥資源的過度消耗,加重患者和社會的經濟負擔。而在我國農村地區,由 于卫生资源匮乏和管理机制落后,其不合理用藥问题更值得关注。 目的: 本研究旨在通過分析西部農村地區醫療衛生機構的門診處方數據, 了解農村地區合理用藥的基本情況,評價用藥的合理程度,探討其中可能存在 的地區差異現象;探索合理用药的影響因素,針對不合理用藥問題提出相應的 建議,為西部農村衛生政策的制定提供參考依據。 方法:本研究為回顧性研究。在中國西部 7 個省/自治區(甘肅省、廣西壯 族自治區、貴州省、寧夏回族自治區、四川省、西藏自治區和新疆維吾爾自治 區)開展抽樣調查,每個省根據經濟發展水準(人均 GDP)好、中、差的標準, 抽取 3 個樣本縣,調查其縣醫院、中醫院和婦幼保健院;每個縣的鄉鎮根據人 口數量從大到小排列,採用系統抽樣的方法抽取 3 個鄉鎮衛生院為樣本衛生院; 每個鄉鎮抽取 3 所村衛生室作為調查對象。在上述 172 家樣本醫療機構內按處 方號隨機抽取 2011 年門診處方每月各 15 張,每所醫療機構理論上共抽取 180 張,實際錄入的有效門診處方共 30572 張。依據世界衛生組織基本藥物行動委 員會(WHO/DAP)編寫的發展中國家醫療機構合理用藥評價指標,描述醫療機構 處方用藥的情況。採用 F 檢驗和卡方檢驗分析不同地區或不同級別醫療機構的 各項合理用藥指標值的差異。利用綜合評價法量化描述各地處方合理用藥的整 體情況。採用多元回歸和因子分析法分析合理用药的影響因素。 結果:中國西部農村醫療衛生機構藥品合理使用情況不容樂觀,各省(自 治區)平均單張處方用藥 3.8 種;抗菌藥物處方比例高達 57.3%,超過 WHO 標 準平均值 144.8%;注射處方比例高達 33.9%,超出 WHO 標準平均值 80.3%。 iv 各級醫療機構的合理用藥情況均存在地區差異:以鄉級醫療機構為例,不 同地區鄉級醫療機構抗菌藥物處方比例不同( 2 = 44.847,P = 0.000),注射 處方比例不同( 2 = 45.081,P = 0.000),激素處方比例不同( 2 = 26.234,P = 0.000),基藥處方比例不同( 2 = 141.145,P = 0.000)。其中新疆的不合理 用藥情況較其他地區更為嚴重,其抗菌藥物處方比例為 77.1%,超出 WHO 標 準平均值 230.3%,注射處方比例為 47.6%,超出 WHO 標準平均值 153.2%。不 同地區的縣級和村級醫療機構門診處方的抗菌藥物處方比例、注射處方比例和 基藥處方比例均有所不同(P < 0.05)。各省(自治區)合理用藥綜合評價分 數結果顯示,貴州(84.2 分)、寧夏(76.0 分)和西藏(84.2 分)合理用藥情 況較好;甘肅(69.3 分)、四川(62.4 分)和廣西(60.7 分)合理用藥情況中 等;新疆(55.8 分)合理用藥情況較差。 中成藥處方占農村基層醫療機構處方總數的 62.47%,縣、鄉、村級醫療機 構這一比例分別為 49.76%、56.96%和 71.51%。縣、鄉、村級醫療機構單張處 方使用中成藥的品種數分別為 1.38、1.91 和 2.54 種,處方平均藥費金額分別為 52.20 元、21.89 元和 19.37 元,中成藥基藥使用率分別為 37.25%,32.14%和 25.79%。 對農村醫療機構門診處方費用影響最大的變量為醫療機構的級別(縣級、 鄉級、村級);此後依次為中成藥的種數、是否使用注射劑、是否聯用抗菌藥 物。影響合理用藥綜合評價分數的因素有支付負擔因素(處方總費用和中成藥 費用)、處方因子(抗菌藥物處方比例、注射處方比例、處方基本藥物比例) 和管理因素(財政補助和藥品收入占醫療機構總收入的比例)。 結論:我國西部農村醫療衛生機構普遍存在不合理用藥現象,集中體現在 抗菌藥物和注射藥物的過量使用。不同地区門診處方合理用藥情况存在差异, 其中新疆的不合理用藥情況較其他地區更為嚴重。處方費用受到医疗机构級別 的影響最大。合理用藥情況不僅與處方因子有關,還受到支付負擔和管理因素 的影響。相關部門在促進農村地區合理用藥的同時,還應根據農村各級醫療機 構的具體需求和不同地區的用藥特點,調整衛生政策,加強中成藥處方品質控 制,完善處方合理用藥及費用的管理。

Issue date

2017

Author

羅爾丹

Faculty

Institute of Chinese Medical Sciences

Degree

M.Sc.

Subject

Drug utilization -- China, Northwest

藥物使用情況 -- 中國西北部

Drug utilization -- China, Southwest

藥物使用情況 -- 中國西南部

Rural health services -- China, Northwest

鄉村健康服務 -- 中國西北部

Supervisor

卞鷹

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