| In 2015,the zero-markup policy of essential medicines would be put into effect in every government-run healthcare institution,such as Anhui province,when proceeding of health care system reform was in depth.How to implement the preferential use of essential medicine is one of the important problems,especially with multiple principal-agent linkages.This present study takes county public hospitals of Anhui province as the study sample according to the principal-agent characteristics of essential medicine,and explore how to establish a total capacity incentive mechanism of essential medicine used in county public hospitals.Drug utilization analysis is used to analyze the current status and the burden of disease of the public hospitals,and to study the rational administration of the baseline data of drug usage.Then based on the field investigation,we use structural equation model(SEM)to define and analyze the influential factors of essential medicine in comprehensive public hospitals.It was quantitatively analyzed that the relationship between the influencing factors and the influencing degree of all relevant factors on the internal mechanism of action.These theoretical frameworks was re-evaluated by questionnaire on the subject,object and environment system,and also to verify that the method of the mechanism established can be used in different hospitals and different areas.It also provides basis for decision making and methodological support for the establishment of the county public hospitals essential medicine system,and the smooth development of comprehensive health system reform in public hospitals.Part 1.Prevalence study on the utilization of essential medicine used in county public hospitals of Anhui province.Objective:This paper mainly studies the redistribution of medical resources which lead to the changes of principal agent model of each stakeholder under the new health reform and effects caused by the changes on the use of essential medicines.Methods:By using medicines utilization research methods,we collect the initial data about medicines consumption of county public hospital before and after the implementation of the essential medicine system for three consecutive years,calculate medicines utilization index such as composition ratio of medicines use;DDDs and usage of essential medicines and antibiotics,evaluate quantitatively baseline data of medicines use,and survey the tendency change of essential medicines used in Anhui Province public hospitals from the availability,affordability,rational administration.Results:(1)The overall composition changes of the medicines used from 2011 to2013:Except for Chinese Herbal Medicine,the six county hospitals use 575~4037species of medicines(different formulations,different specifications of the medicines included in a separate,focused on the actual use of the medicines).A、B、C counties use more species of western medicine among these,the constituent ratio is about 60%to70%,including oral and injective chemicals.There was a significant difference(χ~2=243.779,P﹤0.01)on the species composition of medicines consumed in three annual samples before and after the implementation of health reform.Meanwhile,from the point of view on the specific number of years,the problem about the usage of injective traditional Chinese medicine what pharmacovigilance concerns about,has increased.Statistical analysis also showed an significant differences:χ~2=28.428,P﹤0.01.According to the classification of pharmacological action,the top three of western medicines what the three county-level medical institutions used in three years were antibacterial medicines(12.92%),cardiovascular medicines(11.61%)and digestive system medicines(8.42%).The top three of the traditional Chinese medicine were internal medicine(66.03%),surgery(8.45%)and gynecological medicines(7.70%).(2)The composition changes of the antibiotics used from 2011 to 2013:According to the overall composition of medicines use in A,B,C three county hospital from 2011 to2013,we know that the proportion of antibacterial always ranked the first step.The species and consumption of anti-infective medicines also showed increasing trend year by year,an average anti-infectives consumption of three county hospitals were5,399,752 yuan in 2011,12,658,772 yuan in 2012 and 15,199,827 yuan in 2013.But its proportion of the total hospital medicines cost has no significant difference;the top four were cephalosporins,penicillins,quinolones and macrolides,of those the DDDs ratio of cephalosporins changed from 18.15%in 2011 to 37.13%in 2012,and reached 52.62%in 2013,then combined with cephalosporins consumption,the result indicated that the DDDs of cephalosporins increased year by year.(3)The composition changes of the essential medicines used from 2011 to 2013:Analyze and deal with the medicine consumption,during those three years,the proportion of medical insurance medicine used was higher,C County accounts for 97.73%,it’s the highest proportion(essential medicines accounts for 30.68%).Expenditure date was analyzed to calculate the proportion of medicines list,this results show that the total amount of the medical insurance sales accounted for the overall at a high level,above 80%;and the amount of essential medicines sales accounted for only 50%of the total amount of the medical institutions at the county level.(Only C County of essential medicines accounted for61.53%in 2011).A lowers proportion of essential medicines sales were amount,partly because of the low usage of essential medicines,and the generally low unit price of essential medicines.Conclusion:(1)The comparison between those three regions in the three years shows,there is significant difference in the species of medicines used,it may be related to the regional demographic composition and stratification of the economic.According to the classification of pharmacological action,the top three of western medicines what the three county-level medical institutions used in three years were antibacterial medicines,cardiovascular medicines and digestive system medicines.(2)The proportion of antibacterial always ranked the first step,but there was no significant difference in its proportion of the total hospital medicines cost;The top four were cephalosporins,penicillins,quinolones and macrolides.(3)The proportion of essential medicines use was lower than medical insurance medicines.These data indicate that the county medical institutions clinicians prefer to use these medicines in the medical insurance catalog,they have lower attention to the rational use of essential medicines in clinical.Part 2.Analysis of the key factors influencing the priority use of essential medicines in the public hospitals of Anhui ProvinceObjective:Empirical study was conducted to analyze the behavior of physicians prescribing essential medicine based on the theory of planned behavior.The effectiveness of the essential medicines’priority use in the range of public hospitals is ultimately reflected in the behavior of the physicians in prescribing essential medicines.This section will qualitatively and quantitatively analyze the decision-making approach of physician prescribing essential medicine.Methods:Based on the theory of planned behavior and combined with the results of the first part of the medicine consumptions,the project analyzed the behavior intention of the medicine use of physicians.Structural equation model was used to investigate the physician pre-scribing essential medicine so as to explore influential factors from behavioral attitude,subjective norms and perceived behavioral control.Five hypothesis were put forward as the following:H1:The attitude towards physicians’cognition of essential medicine system has a positive effect on the basic behavior of prescription;H2:Other important supports and the extent of institutional environment have a positive effect on the basic behavior intention of prescription of essential medicines;H3:The control extent of cognition behavior has a positive impact on the behavior intention of the basic prescription medicines;H4:The control extent of cognition behavior has a positive effect on actual behavior of the priority of essential medicines;H5:The behavior intention of the priority use of essential medicines has a positive effect on the actual behavior of the prescription of essential medicines.Results:(1)The sample of this study is the physician in county public hospitals in Anhui provinces,this paper analyzes the factors and their interrelationships by structural equation.(2)Confirmatory factor analysis showed that the subject to the structural equation model parts fit better with the actual survey data;Path analysis showed that the attitude of physicians preferred prescribing essential medicine has positive effects on behavioral intention;Other important people’s support and the extent of institutional environment,subjective norm,perceived behavior control on the behavior of physicians prescribing essential medicines have a significant positive effect;But the control extent of cognition behavior of physicians prescribing doesn’t have a significant positive effect on actual behavior of the priority of essential medicines;The behavior intention of physicians has a direct positive effect on the actual behavior of physicians preferred prescribing essential medicines.Conclusion:(1)The structural equation model formed better reflected the main influential factors of physician prescribing essential medicine.(2)Physician are not aware of the policy design and implementation details on the health care reform. Behavioral attitude influences physician’s intention to prescribing essential medicines significantly but not intensively while subjective norms and perceived behavioral control also influence the prescribing behavior positively.Based on exploring the status of essential medicines used in medical institutions at county level,the present study analyzed the key factors influencing the priority usage of essential medicines by structural equation,it counld help for making suggestions on rational use of essential medicines in comprehensive public hospitals,and provide a novel methodology for decision-making during the process of public hospital reform. |
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