Study On Rational Use Of Drugs In 3-level Medical Organizations In Rural Areas Of Western China

1.ObjectivesIt has been more than three years since the "Ministry of Health-UNICEF Project of Primary Health Care (PHC)" (2001-2005) was initiated in Western China. As an important part of the project, the endeavors on rational use of drugs in rural areas has greatly improved the drug circulation system and regulated the iatric conducts of both town and village health workers. What is more, the abuse of antibiotics and hormone has reduced sharply with the application of the standard prescription for village doctors and the generalization of the essential drugs directory for village level. However, there is no subtle research on the irrational drug use in the town hospital, which is the main part of the rural PHC system at present. Furthermore, there is lack of necessary quantitative data and relevant evaluation about the drug use in county hospitals which play a very important role because of the technological support it provided. Moreover, there is no practical understanding about the things such as the drug stock and expenditure, the normalized management of drugs use, and the tech-supervision, feedback and operational mechanism of the project in the 3-level medical organizations. Meanwhile, there are many concerns about how the project gets along, what about the general effect, what's the bottleneck, and so on. These issues not only relate to whether the ultimate goal can be achieved, but also can provide valuable reference for the reform of China rural health and policy making.The objectives of this research included: to review and estimate the effect of the rational drug use promoting project and find out the problems in the execution of the project; to analyze thoroughly the severity of irrational drug use, explore comprehensive and constructive intervention strategies and measures; to" make practical recommendations on the essential drug policy performing, enrich the implication of rational drug use, and enhance feasibility of the policy by longitudinal comparison of irrational drug use in 3-level medical organizations. Meanwhile, this study intended to explore further the role of the mass advertised bidding and the integrated management of village and town medical organizations in rational drug use. On the other hand, by summarizing the information about the use of standard prescription and essential drug, this research would provide idea in revising and improving prescription. In addition, the study was designed to find out the joint of China New Cooperative Medical System and rational drug use policy and to bring forward some politics advices.2. MethodsThe research contains four parts:Part 1: Analysis of rational drug use of prescription in 3-level medical organizationsIn the selected five project counties in western regions, outpatient prescriptions from 10 village health posts, 5 town medical centers and 5 county hospitals were randomly sampled. The severity of their irrational drug use was analyzed thoroughly and the effect of the intervention measures was evaluated.Part 2: China New Cooperative Medical Service and Rational Drug Use Descriptions were sampled from Longde County Hospital, Ningxia Province. The situation of drug use was analyzed. And the position and functions of CMS in the promotion of rational drug use were explored.Part 3: Analysis of drug purchase-sale system in 3-level medical organizations andrational-drug-use intervention measures.This section analyzed thoroughly the significant meaning of mass advertised biddingin county level and the integrated management of village medical organizations onrational drug use. It also summarized the actual situation of the application of standardprescription and essential drug in western rural areas and tried to find out the existingproblems.Part 4: SummaryThe conclusion would be drawn out systematically. Feasible advice would be put forward after analyzing urgent problems about rational drug use in village medical organizations. Finally, the innovation of the research will be concluded and advice for the further study would be given.In brief, the main methods used in this study are as the following:Rapid Evaluation Method: firstly ascertain indicators of rational drug use, thenanalyze the situation by quantitative, qualitative and participative investigationmethod;Descriptive analysis: calculating the indicators such as means, rates to show theobjective situation of rural medical organizations;Comparing analysis: using chi-square test to compare the difference of variousindicators;Multivariate analysis: using multiple stepwise regression to select the maininfluencing factors of description fee.3. Results3.1 Irrational drug use in county hospital is serious and common, and should receive sufficient attention.In 3873 prescriptions from county hospitals, the average number of drug was 3.21 per prescription; and 3.85% of all the prescriptions contained 9 or more kinds of drugs. It shows that the combined use of drugs is usual. The average prescription fee was 32.60 yuan in spot-checked prescriptions, in which the highest was 978 yuan, and 5.99% of which were over 100 yuan. The abuse of antibiotics was prominent, which mainly included over dosage, unreasonable administration mode, repeated use of drugs, combining use of drugs of the similar function, and so on. In 60 kinds of drugs that were mostly often used, antibiotics accounted for 54%. Of all prescriptions sampled, 45.34% contained 1 or more kinds of antibiotics, and 16.21% contained 2 kinds of antibiotics. The use of hormone also had some unreasonable factors. Ten in every 100 prescriptions used hormone. Antibiotics and hormone combined use could be seen in 4.98% of the sampled prescriptions. The injection rate is high, and there are 26 using injections in every 100 prescriptions. Of all the injection prescriptions, the intravenous mode accounted for 58.40%. Compared with the criteria of WHO, the values of all the above indicators were obviously higher, which shows that the irrational drug use is serious and general.3.2 The situation of irrational drug use in town hospital was improved within a limited degree and the execution power of intervention measures was weak.In 3733 prescriptions from town hospitals, the average number of drugs was 2.33 per prescription; the average fee was 32.60 yuan. Among all the selected prescriptions, the highest fee was 615 yuan. Although the prescriptions of less than 20 yuan accounted for as high as 78.04%, the unreasonable exorbitant prescriptions are not rare. Of all the prescriptions, the fee over 50 yuan accounts for 4.74%, while those with over 100 yuan accounted for 0.88%. Of the most often used drugs, antibiotics contributed 46.99%; and the hormone accounted for 8.52%. Of all the prescriptions, 13.10% contained 2 or more kinds of antibiotics. There is no statistical significance between the 2003 and 2004 with regard to the above indicators. The total injection rate is still as high as 34.53% in recent years though it is obviously lower than before in some town hospitals. Compared with the criterion of WHO rational drug use indicators, although the average number of drugs in single prescription is a bit smaller, the situation of antibiotics and injection use, as well as hormone, is not so optimistic. The comparison analysis of prescription of recent two years shows intervention measures in the rural primary health care project did not have significant effect.3.3 The status of irrational drug use in village health posts has been improved significantly; the awareness of rational drug use has been strengthened.In 3206 prescriptions from village health posts, the average number of drugs was 2.20 per prescription; the average fee was 3.16 yuan. Among all the prescriptions, the highest was 42.60 yuan and the lowest is 0.1 yuan. The prescriptions with the fee less than 10 yuan accounted for 97.41%, and the unreasonable exorbitant prescriptions were very rare. Although the rate of using antibiotics is as high as 44.79%, there were big difference among different areas. The administration mode tended to be more reasonable, and the prescription drugs were mainly based on the village-level essential drug directory. As for the use of hormone, there are only 1.53 in 100 prescriptions containing hormone, and the use of hormone reduced obviously along with time passing. In some project counties, the use of hormone was even not found. All of these shows that the abuse of hormone has been successfully controlled. The combining use of antibiotics was not common, for example, the proportion of 2 or more antibiotics combining use was only 8.00%, which shows a declined trend year by year. Unsafe injection and injection abuse has been successfully controlled. There were only 32 prescriptions which contained intravenous mode in the total 410 injection prescriptions, i.e. 92.20% of injection were carried out in intramuscular or subcutaneous mode, which is safer than intravenous mode. We can see from the above results that all the values of indicators except for the proportion of antibiotics use satisfied the WHO criterion. This also demonstrates sufficiently the significant effect of the intervention measures.3.4 CMS has a great promotion impact on Rational Drug UseWith regard to CMS prescriptions, the average number of drug was 2.19 per prescrioption; the average fee was 13.05 yuan. Among all the selected prescriptions, the highest fee was 65.60 yuan and the lowest was 0.44 yuan. The use of drugs were strictly based on the CMS essential drug directory. The proportion of antibiotics use was 46.67%; and the proportion of combining use of 2 or more antibiotics was only 9.20%. The proportion of hormone was 5.06% and injection was 6.67%. Compared with the prescription in ordinary outpatient departments in this project county, all of the indicator values are lower; Comparing with the total level of the 5 western counties, the value of every indicator was obviously lower except that the proportion of antibiotics was slightly higher. These results imply that CMS has a good passive effect on regulating drug use and decreasing both the description fee and irrational injection.3.5 The multivariate analysis of description fee provides reference for rational drug useThe results of multiple regression shows the number of drugs in spot-checked prescriptions contributed the most to the prescription fee; use of antibiotics or injection increased the fee; and some common diseases such as the respiratory system diseases had some influences on the fee. The results indicate that in order to cut down the description fee, it is essential to start with the regulation of description behaviors, which include strict controlling of the number of drugs in single prescription and the rationality censoring of antibiotics and intravenous injection.3.6 The improvement of the supply and marketing system of drugs in rural areas show the security and economy of rational drug useBoth the mass advertised bidding in county level and the integrated management of village medical organizations assured originally the quality of drugs and lowered the price of drugs, which shows the security and economy of rational drug use. Although there are many problems and difficulties in the executive process, the effect of the system on regulation of the drugs markets in rural areas should be affirmed. Especially for the basic level medical institutions, the effect of drug quality ensuring is significant; and the effect of promoting drug rational use begins to appear.3.7 The standard prescription and essential drug directory are the core intervention to promote rational drug useThe rural basic medical institutions play the most direct and important role in the practice of rational drug use, and is also the most determinant segment. With their close relationship and mutual promotion, the standard prescription and basic drug directory play a key role in supplying medical drug, protecting the right of drug using for rural population, as well as controlling prescription fee, safety, efficiency and rationalization of drug use.4. Innovations4.1 By analyzing thoroughly and systematically the situation of drug use in 3-level medical organizations in rural areas and evaluating the influencing factors, the significant effect of the rural primary health care project on promotion of rational drug use has been affirmed, and the degree of irrational drug use in every level medical organizations has been analyzed deeply.4.2 This study explored deeply the close relationship between CMS and Rational Drug Use, and draw out conclusion that the basic drug policy is not only the important part of rational drug use, but also is the hinge to further improve the CMS.4.3 The research analyzed thoroughly the effect of mass advertised bidding in county level, the integrated management of village medical organizations and the standard prescription on rational drug use, and found out the existing problems and brought forward intervention measures.