| [Background]At present, unrational drug use, adverse effect of drug, drug-induced diseases and bacterial drug resistance become more serious and these have brought heavy burden to individuals and the society. Rational drug use has been paid more and more attention.Rational drug use includes four aspects:safety, effectiveness, economics, appropriateness. In 1993, International Network for Rational Use of Drugs has published "How to investigate drug use in health facilities (selected drug use indicators)" which has raised several indicators about rational drug use. WHO has issued 12 central polices and measures to promote the rationality of drug use in 2002. It includes three contents:education, management and regulations. How to determine the indicators for the assessment of rational drug use in medical institutions is a global problem. In 2002, U.S. Agency for International Development published "How to Investigate Antimicrobial Drug Use in Hospitals:Selected Indicators", and designed hospital antimicrobial drug research indicators and research method. At present, these indicators have been used widely.[Purposes]The purposes of the study were to analyze the rationality of drug use in the community health centers of one district in Shanghai ("A district" will be used in the followings); to analyze the influential factors that affect the drug expenses in the above community health centers; and to develop the monitoring indicators for the rational drug use in the community health centers.[Contents]The study contents included: 1. the analyses on the resources and operational conditions of the community health centers of A district in 2009;2. the analyses on the rationality of drug use in out-patients and in-patients of the community health centers of A district in 2009;3. the analyses on the factors that affect the drug expenses in the main diseases of out-patients and in-patients in the community health centers of A district in 2009;4. the assessment of the rationality of drug use in the randomly selected in-patients medical records in the community health centers of A district in 2009;5. the development of the monitoring indicators for the rational drug use in the community health centers of A district.[Methods]The methods used in the study were:1. Literature reviewIn the study, the articles related to the rationality of drug use and published in the national and international journals in 2005-2009 were reviewed, the qualitative and quantitative indicators and assessment methods for the evaluation of rationality of drug use were collected, and the laws and regulations related to rationality of drug use and issued after 2000 were also collected.2. Existing data collectionThe data of drug use in out-patients and in-patients and some information related to the patients and physicians in the community health centers of A district in 2009 were collected from the HIS of A district.3. Assessment of inpatient medical records by exportsRandomly selected the medical records of the 120 inpatients that had cerebral infarction and discharged in community health centers of A district in 2010 were reviewed by two clinical experts in neurology. The exports assessed the rationality of therapeutic drugs used in inpatients during the first 14 days in the community health centers.4. Development of monitoring indicatorsAccording to the previous study results, monitoring indicators for the rationality drug use and their standards were determined, and the monitoring of the rationality of drug use were imitated in the community health centers of A district.5. Statistic analysesDescriptive statistical methods used in the study included mean values, percentiles; Kruskal-Wallis test orχ2 test were used to compare the differences in the indicators between or among the groups. The multivariate linear equation and multivariate logistic analyses were used to analyze the factors that affect the expense of drugs.[Results]The main research results were as following:1. Conditions of the community health centersIn 2009, the average stuff number of the community health centers in A district was 210, the average number of on-duty health personnel in the centers was 172, the average number of actually opened beds in the centers was 182. In addition, the average outpatient visits and the average inpatients of the community health centers were 505555 and 1565 respectively.2. Analyses on the rationality of drug use in community health centersThe sampled 34145 outpatient electronic prescriptions were targeted toward 942 kinds of first diagnoses and 895 drugs in the community health centers of A district. The average expense of one outpatient drug was 33.71 yuans, the average expense of one outpatient prescription was 78.06 yuans, and the average drug number of an outpatient prescription was 2.32. Antimicrobial drugs accounted for 13.10% of the times and 12.46% of the expenses of outpatient prescription drugs. The outpatient prescriptions that included antimicrobial drugs accounted for 26.43% of all prescriptions. The injection solutions accounted for 15.51% of the times and 13.45% of the expenses of outpatient prescription drugs. The outpatient prescriptions that included injection solutions accounted for 13.78% of all prescriptions. National essential drugs accounted for 39.94% of the times and 29.27% of the expenses of outpatient prescription drugs. The sampled 1787 inpatient cases involved 143 kinds of first discharge diagnoses and used 570 drugs in the community health centers of A district. The average total expense for medicine (includes Chinese herbal medicine) for each case was 1256.05 yuans. Antimicrobial drugs accounted for 13.31% of the times and 24.91% of the expenses of inpatient drugs. The injection solution accounted for 62.15% of the times and 61.19% of the expenses of inpatient drugs. National essential drug accounted for 69.31% of the times and 42.51% of the expenses of inpatient drugs.3. Analyses on the factors that affect the drug expenses in community health centersThe research showed that for the outpatients with one of the 5 top diseases (hypertension, upper respiratory tract infection, coronary heart disease, diabetes, bronchitis), the total medicine expenditure was related to the patient’s gender, the number of drugs in prescription, drug type, physician’s gender and professional title, and the types of patient payment. For the inpatients with cerebral infarction, the total medicine expenditure was related to the gender and age of patients, the number of drugs in a prescription and the type of drugs.4. Assessment of the drug use in inpatients with cerebral infarction in community health centersIn 120 randomly selected medical records of the inpatients with cerebral infarction, the mean scores for effectiveness, safety, economics and appropriateness of the therapeutic drugs that used during the first 14 days were 3.68,3.79,3.84 and 3.82 respectively.5. Development of monitoring indicators for the rationality drug use and their standards in community health centers10 monitoring indicators for outpatient drug use and 10 for inpatient drug use were determined, including the average number of drugs in a prescription, antimicrobial prescription proportion, injection prescription proportion for outpatients and the average number of drug use, the average number of drugs used in one day, the proportion of antimicrobial agents for inpatients. The standards for these monitoring indicators were determined according to the related percentiles.6. Imitation of the monitoring for the rationality of drug useThe imitation of monitoring outpatient drug use in 12 community health centers of A district showed that abnormal rate was 10.15% in 2009. In addition, the immitation of monitoring the drug use in inpatients with cerebral infarction in 12 community health centers showed that abnormal rate was 7.87%. The analyses also showed that the abnormal rates were varied among different community health centers and among different months.[Discussion and Suggestions]The study found that, A District Community Health Service inpatient and outpatient service make the types of drugs and expenditure used in a more reasonable way; It is low-percentage usage about antimicrobial drugs and injection; The ratio of National Essential Drugs should be improved.The authors believed that the number and the expenditure of drugs in outpatient prescriptions in 2009 were relatively reasonable, that the proportions of the use of antibacterial drugs as well as injection solutions in 2009 were low, and that the proportion of the national essential drug use should be increased in community health centers of A district. In 2009, the drug expenditure for an inpatient was low, drug types were centered, and the proportion of the national essential drugs use was relatively high in community health centers of A district. To resolve the problems of unrational drug use, the joint efforts from the health administrative department, medical institutes, medical personnel and patients were needed. On one hand, community health centers should strengthen the management of prescription behaviors of physicians; on the other hand, the government should monitor the drug use in community health centers. |
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