本文關(guān)鍵詞：安徽省三級(jí)醫(yī)院臨床用藥趨勢(shì)分析及合理用藥策略研究　出處：《安徽醫(yī)科大學(xué)》2015年碩士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 公立醫(yī)院 藥物利用 合理用藥 醫(yī)藥衛(wèi)生體制改革

【摘要】：構(gòu)建藥品供應(yīng)保障體系,促進(jìn)臨床合理用藥一直是我國(guó)深化醫(yī)改的重要工作之一。我國(guó)曾采用的藥品加成政策是醫(yī)療機(jī)構(gòu)中藥品價(jià)格形成的主要方法,曾經(jīng)對(duì)保障醫(yī)療機(jī)構(gòu)正常運(yùn)行發(fā)揮了非常重要的作用。但是近些年來,這項(xiàng)政策誘發(fā)了醫(yī)療機(jī)構(gòu),特別是個(gè)別的醫(yī)務(wù)人員在醫(yī)療活動(dòng)中開大處方、開貴藥的情況,給患者增加了經(jīng)濟(jì)負(fù)擔(dān),尤其對(duì)臨床合理用藥和藥品供應(yīng)保障產(chǎn)生不良影響。在我國(guó)新一輪醫(yī)藥衛(wèi)生體制改革中,取消藥品加成、斬?cái)噌t(yī)藥利益鏈成為亟待解決的重要問題。三級(jí)綜合性公立醫(yī)院改革目前是我國(guó)深化醫(yī)改的重要工作領(lǐng)域,尤其是目前安徽省以推進(jìn)公立醫(yī)院轉(zhuǎn)換運(yùn)行機(jī)制為核心,實(shí)行取消藥品加成、調(diào)整醫(yī)療服務(wù)價(jià)格、實(shí)施藥品帶量采購(gòu)“三同步”的改革過程中,摸清三級(jí)綜合醫(yī)院藥品使用的現(xiàn)況,對(duì)順利實(shí)施綜合性公立醫(yī)院改革,構(gòu)建適應(yīng)改革需要的績(jī)效評(píng)價(jià)體系均有重要參考意義。為了使調(diào)研結(jié)果具有更好的代表性,本課題以安徽省三級(jí)綜合性公立醫(yī)院為調(diào)查對(duì)象,根據(jù)安徽省不同地區(qū)以及經(jīng)濟(jì)發(fā)展的特點(diǎn),采用分層隨機(jī)抽樣調(diào)查方法,共抽樣5個(gè)地區(qū)三級(jí)醫(yī)療機(jī)構(gòu),對(duì)5家醫(yī)院在醫(yī)改前后分別2008年、2013年的所有藥品消耗情況進(jìn)行分析。從藥品可獲得性、可負(fù)擔(dān)性、合理用藥三個(gè)維度,經(jīng)文獻(xiàn)調(diào)研選用醫(yī)改效果評(píng)估的核心指標(biāo)及合理用藥調(diào)查指標(biāo)體系,采用藥物利用研究方法對(duì)我省三級(jí)綜合醫(yī)院藥物使用的情況進(jìn)行評(píng)價(jià),探討醫(yī)改實(shí)施過程中安徽省三級(jí)公立醫(yī)院藥物使用可能存在的問題,在安徽省醫(yī)改新形勢(shì)下,為促進(jìn)臨床合理用藥、構(gòu)建完善的藥品供應(yīng)保障體系提供政策建議。主要內(nèi)容概括如下：1.安徽省三級(jí)公立醫(yī)院醫(yī)療機(jī)構(gòu)藥品使用的總體構(gòu)成收集5家三級(jí)醫(yī)院2008年1月1日至12月31日、2013年1月1日至12月31日前后兩年使用的藥品數(shù)據(jù),分別計(jì)算以下指標(biāo)。1.1藥品使用金額分析計(jì)算2008年、2013年所有品種藥品使用的總金額,可以用于比較不同地區(qū)的藥品資源消耗水平。同時(shí)按照銷售金額進(jìn)行排序,得出排名前20位的藥品品種。結(jié)果顯示,2008年金額排序前十的藥品為：神經(jīng)節(jié)苷脂鈉、奧美拉唑鈉、頭孢孟多、頭孢替安、頭孢甲肟、重組人白細(xì)胞介素-Ⅱ、奧拉西坦、左氧氟沙星、頭孢吡肟、頭孢西��；2013年金額排序前十的藥品為：神經(jīng)節(jié)苷脂鈉、奧拉西坦、頭孢替安、泮托拉唑、多西他賽、甲磺酸伊馬替尼、小牛血清去蛋白、頭孢西丁鈉、艾迪、復(fù)合輔酶。1.2用藥頻度(DDDs)分析計(jì)算2008年、2013年所有品種藥品使用的DDDs值,結(jié)果顯示,2008年DDDs排序前十的藥品為：維生素C注射液、單硝酸異山梨酯、維生素C片、曲美布汀、克拉霉素、頭孢克肟、尼群地平、左西替利嗪、厄貝沙坦、伊曲康唑；2013年DDDs排序前十的藥品為：維生素C注射液、氨氯地平、硝苯地平、維D鈣、凝血酶、單硝酸異山梨酯、雷公藤多苷、地高辛、白芍總苷、利可君。2.安徽省三級(jí)公立醫(yī)院醫(yī)療機(jī)構(gòu)藥品使用的分類構(gòu)成在分析所有藥品總體構(gòu)成的基礎(chǔ)上,按照藥理作用分類,分別研究?jī)蓚�(gè)年度各類藥品的使用金額和藥品用藥頻度構(gòu)成情況,更為具體地探討臨床各類藥品使用可能存在的不合理現(xiàn)象。2.1抗微生物類藥品使用金額及用藥頻度分析2013年較2008年抗微生物藥使用金額及用藥頻度均小幅增長(zhǎng)(分別為32.03%和13.94%),遠(yuǎn)較藥品總使用金額及總用藥頻度增長(zhǎng)幅度小(分別為212.99%和81.47%)。2013年的抗微生物類藥品中碳青霉烯類、糖肽類大分子抗菌藥使用金額進(jìn)入排名前20位。相較與2008年,2013年的氨基糖苷類抗菌藥物使用頻度排名跌出前20名,大環(huán)內(nèi)脂類使用頻度有所增加。2.2神經(jīng)系統(tǒng)用藥藥品使用金額及用藥頻度分析2013年較2008年神經(jīng)系統(tǒng)用藥金額及使用頻度均出現(xiàn)大幅增長(zhǎng)(分別為323.76%和136.27%)。用藥金額增長(zhǎng)幅度遠(yuǎn)大于使用頻度增長(zhǎng)幅度,說明神經(jīng)系統(tǒng)用藥以價(jià)格較為昂貴的藥品增長(zhǎng)為主。2013年?duì)I養(yǎng)腦神經(jīng)藥物取代調(diào)節(jié)腦血流、腦代謝藥物成為神經(jīng)系統(tǒng)用藥金額中占比最大類,但使用頻度中調(diào)節(jié)腦血流、腦代謝類藥物仍占神經(jīng)系統(tǒng)用藥最大比例。2008年及2013年兩年使用金額最大的藥品均為單唾液酸四己糖神經(jīng)節(jié)苷脂。2.3消化系統(tǒng)用藥藥品使用金額及用藥頻度分析2013年較2008年消化系統(tǒng)用藥金額及使用頻度均有較大增長(zhǎng)(分別為249.94%和76.24%)。2008年及2013年消化系統(tǒng)用藥金額排名前20位均為抑酸藥和肝膽胰疾病用藥,2013年抑酸藥使用金額占比相對(duì)下降,但2013年抑酸藥使用頻度卻相對(duì)上升。2.4循環(huán)系統(tǒng)用藥藥品使用金額及用藥頻度分析2013年較2008年循環(huán)系統(tǒng)用藥金額及用藥頻度均有增長(zhǎng)(分別為268.35%和181.15%)。2013年相較于2008年抗心絞痛、擴(kuò)血管藥物使用金額及使用頻度占比均有下降,利尿藥使用金額占比2013年未進(jìn)入排名前20位。2008年及2013年循環(huán)系統(tǒng)藥品使用頻度排名中抗高血壓藥及抗心絞痛、擴(kuò)血管藥均位于前列,2013年抗心絞痛、擴(kuò)血管藥用藥頻度占比下降。胺碘酮等抗心律失常藥未進(jìn)入使用金額及使用頻度排名前20位�？垢哐獕核幱惺褂梅N類相對(duì)集中趨勢(shì)。2.5激素類藥品使用金額及用藥頻度分析2013年較2008年激素類藥品金額及用藥頻度均出現(xiàn)增長(zhǎng)(分別為189.97%和160.21%)。使用金額與用藥頻度增長(zhǎng)幅度相接近,說明激素類藥品的增長(zhǎng)以使用頻度的增長(zhǎng)為主。胰島素類為激素類藥品中使用金額最大類。2.6營(yíng)養(yǎng)類藥品使用金額及用藥頻度分析2013年較2008年?duì)I養(yǎng)類藥品使用金額及用藥頻度均出現(xiàn)增長(zhǎng)(分別為187.62%和46.41%)。2008年及2013年兩年腸內(nèi)營(yíng)養(yǎng)藥品使用金額均占比很低,2013年占比進(jìn)一步下降。腸外營(yíng)養(yǎng)中脂肪乳、氨基酸使用金額占比兩年均居于首位,2013年電解質(zhì)、微量元素類藥品出現(xiàn)較大增幅。使用頻度排名中腸內(nèi)營(yíng)養(yǎng)藥2013年進(jìn)入排名前20位,電解質(zhì)、微量元素類藥使用頻度占比也出現(xiàn)較大增長(zhǎng)。轉(zhuǎn)化糖電解質(zhì)在其他相似研究中并未出現(xiàn)在使用金額排名前列中,但在本次調(diào)查中2008年及2013年兩年均出現(xiàn)在使用金額前列中。2.7中成藥藥品使用金額及用藥頻度分析2013年較2008年中成藥用藥金額及用藥頻度均有增加(分別為231.60%和142.27%)。兩年中成藥使用金額排名中輔助抗腫瘤藥均占比最多。2013年及2008年中成藥使用頻度排名中位于首位的均為活血化瘀類中成藥。說明輔助抗腫瘤藥價(jià)格相對(duì)較高。本次調(diào)查中抗腫瘤中成藥位居前列的幾種藥品與其他類似研究結(jié)果基本一致。2.8抗腫瘤類藥品使用金額及用藥頻度分析2013年較2008年抗腫瘤藥使用金額及使用頻度均出現(xiàn)飛速發(fā)展(分別為1053.64%和561.81%)。抗腫瘤靶向藥物在本次調(diào)查中使用金額得到巨大增長(zhǎng),原因主要為安徽省發(fā)病率的增長(zhǎng)及抗腫瘤靶向藥物在臨床使用越來越多且其價(jià)格非常昂貴。3.2008年與2013年藥品使用變化分析從藥品使用金額來看,只有抗菌藥物的使用金額相對(duì)于總金額未取得增長(zhǎng),其他類型藥品均取得較大增長(zhǎng),其中又以抗腫瘤藥物、神經(jīng)系統(tǒng)藥物增長(zhǎng)較快。大部分的藥物增長(zhǎng)有合理解釋,但部分藥品如轉(zhuǎn)化糖電解質(zhì)存在不合理的快速增長(zhǎng)現(xiàn)象。從藥品使用頻度來看,抗菌藥物、中成藥、神經(jīng)系統(tǒng)藥物及消化系統(tǒng)藥物相對(duì)于總DDDs的增長(zhǎng)幅度未取得增長(zhǎng),其他類型藥物均取得使用頻度的增長(zhǎng),其中又以抗腫瘤用藥頻度增長(zhǎng)幅度最大。綜合兩者可以看到只有抗菌藥物在使用金額及使用頻度上相對(duì)于總金額及總使用頻度均出現(xiàn)大幅下降,其他類型藥物未見此現(xiàn)象,說明抗菌藥物的臨床濫用現(xiàn)象正在得到控制。而抗腫瘤藥無論藥物使用金額或使用頻度的增長(zhǎng)均居于各種藥品之首,這與抗腫瘤藥物2008年的基數(shù)較小及近年的快速增長(zhǎng)有關(guān)。從中成藥(使用金額增長(zhǎng)231.60%,DDDs增長(zhǎng)142.27%)及神經(jīng)系統(tǒng)藥物(使用金額增長(zhǎng)323.76%,DDDs增長(zhǎng)136.27%)的使用金額大幅上漲,而DDDs增長(zhǎng)較少可以推斷出此兩類藥品使用金額的增長(zhǎng)主要以高價(jià)格藥品增長(zhǎng)為主或使用藥品種類相對(duì)集中引起或使用藥品種類相對(duì)集中引起或使用藥品種類相對(duì)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.

【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類號(hào)】：R969.3

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