Study On Apropritateness And Its Influencing Factors Of Tumor Markers' Requesting

With the limitation of health resources in our country,serious waste exists due to the excessive medical service.Among all kinds of excessive medical services,excessive examination,especially the inappropriate request(IR)of tumor markers(TMs),has been of certain universality both at home and abroad.Therefore,how to take effective measures to restrain excessive medical services has become the focus of medical and health reforms in all countries,and China is no exception.In this paper,request of tumor markers for lung diseases was the research object,with two kinds of diseases,chronic obstructive pulmonary disease(COPD)of acute exacerbation(AE)and primary lung cancer(PLC)as the research diseases.With the methods of literature review,expert consultation and retrospective study of the 4191 AE-COPD and PLC cases‘data from three general hospitals in Shanghai analysis,the best strategy of TM request for AE-COPD and PLC were screened out,and were chosen as the criteria for judging appropriateness of these two kinds of lung diseases' TM request.Base on the criteria,the IT status of TMs for lung diseases in the three hospitals was evaluated,and preliminarily investigate the clinical pathological interventions on TM test for lung diseases to verify the effect on the appropriateness of TM test.Based on the completion of the above content,this research further explored the influencing factors of clinicians prescribing inappropriate TM detection by means of in-depth interviews and questionnaires,combined with relevant economics and management theory,it analyzed the reason of TMIR in depth.At last,it put forward the feasible interventions to reduce the rate of TMIR,and the corresponding suggestions for improving the status of TMIR for lung diseases.The results showed that carcinoembryonic antigen(CEA)+ CYFRA 21-1,CEA + CYFRA 21-1 + neuron specific enolase(NSE),CEA + CYFRA 21-1 + NSE + squamous cell carcinoma antigen(SCC)combination could be the optimal TM request strategy for AE-COPD and PLC.What's more,with the optimal TM request strategy as the appropriateness criteria for two lung diseases,there would be 97.0% of TMIR in the three hospitals surveyed,which showed the seriousness of TMIR of the lung diseases.In addition,the effect of clinical pathway intervention on the lung diseases TM test showed that the clinical pathway could significantly reduce the medical expenses of patients(P <0.05),and significantly improve the efficacy of COPD patients(P <0.05).Through in-depth interviews with clinicians of the three hospitals surveyed in Shanghai and questionnaires of 224 clinicians with prescription rights at all levels of hospitals mainly from Beijing and Shanghai,it found that the appropriate probability of clinicians' behavior of TM test for lung disease in nearly a month was less than 50%,and only 39.7% of the TM request strategies for two cases in the questionnaire answered by the clinicians were appropriate,further confirming the seriousness of inappropriate TM detection for lung diseases.The reasons why clinicians chose inappropriate TM tests are not only their protection of personal interests,avoiding medical disputes and other reasons,and lack of motivation to learn the relevant health economics knowledge,which could have an indirect effect on their behavior,but also clinicians the level of their own diagnosis and treatment and communication skills,which could have a direct effect on their behavior.The past information integrity and complexity of disease,economic condition of the patients,the subjective willingness or compliance of the patients and their families,the anxiety of the patients,the hospitals,policies and the society environment in which the clinicians are located,could cumulate enormous pressure on the practice of clinicians in the entrusted agency relationship with the patient,finally inducing the more inappropriate choice of TM detection strategy.The main conclusions of this paper are as follows: TMIR of the lung diseases is serious;the optimal TM request strategies for AE-COPD and PLC,both are approved by experts,but also are confirmed by clinical data;clinical pathway is an effective way to control TMIR;the type of payment and the clinical condition are the important influencing factors of IR.The analysis of the reason of IR shows that the improvement of medical system,hospital operation and doctor education is the key to help clinicians to choose the best diagnosis and treatment decision.The innovation of this paper can be summarized as following.First,correct distinction of optimal request is the first step to effectively control IR,but so far the criteria for appropriate and inappropriate request were mostly based on clinical guidelines,norms and treatment habits,and were limited to certain medical institutions and specific projects,most of the conclusions are qualitative,which showed great difference between different studies and were lack of large-scale quantitative clinical research.In this paper,AE-COPD and PLC were chosen as the research diseases,and their optimal TM request strategies were got through expert consultation combined with clinical data analysis,which lay a foundation for the formation of distinction between appropriate and inappropriate request.The second is that the key decision maker of the request--clinicians with the right of prescription was focused on,and through the in-depth interviews and questionnaires,making it clear that the TM request strategy was formulated under the influence of external environment such as hospital,policy and society,as well as the manifestation of clinicians' self-motivation and behavioral skills in TM request for lung diseases.Further,by means of economics,management science and information-motivation-behavioral skills model in behavioral intervention theory,it conducted the in-depth theoretical analysis and empirical verification of the reasons for TMIR,which indicated the way of the effective intervention on IR.