Study On The Effect Of Intelligent Audit Of Basic Medical Insurance On The Utilization Of Antimicrobials Of Inpatients

[Purpose]This study analyzed the audit rules related to antibacterials in the Intelligent Audit of Basic Medical Insurance（hereinafter referred to as“medical insurance”）in Wuhan,and theoretically determined the relationship between these audit rules and the utilization of antibacterials.Based on this,throughout understanding the implementation status of the Intelligent Audit of Medical Insurance in the sample hospital,discussing the role of the Intelligent Audit of Medical Insurance in promoting the rational use of antibacterials with empirical data and providing suggestions for further strengthening the supervision of the utilization of antibacterials.[Methods]（1）Clarifing the audit rules related to the utilization of antibacterials in the Intelligent Audit of Medical Insurance in Wuhan and their specific meanings through literature studies and with key informant interviews.In addition,according to the meaning of the relevant audit rules and the commonly used evaluation indexes of the utilization of antibacterials in the research at home and abroad,four analysis indexes were determined,which were the rate of antibacterials violating the audit rules,the rate of antibacterials application（per thousand people）,Antimicrobial use density（DDDs/100 patient days）,and the submission rate of pathogenic samples of patients using these antibacterials.（2）Obtaining revant data of sample hospitals through on-site investigation.First of all,obtaining violation result of antibacterials in the sample hospital from Intelligent Audit of Medical Insurance system in Wuhan after the system went online（March 1,2016）to December 31,2017,including the types of antibacterials with violation records and the number of antibacterials violated the audit rule.And taking antibacterials which had violated the audit rule as the target antibacterials of this study.Secondly,selecting the inpatients from the electronic medical record system who met with the following conditions as study object:discharging between January 1,2014 and December 31,2017,who had used the above-mentioned antibacterials and the mode of payment was medical insurance of Wuhan city.Collecting the data of study object from the electronic medical record system of sample hospital,which included the medical record home page,the checklist of medical cost and so on.After Intelligent Audit of Medical Insurance was launched,the violation data of antibacterials was obtained from the system.Before the Intelligent Audit of Medical Insurance was launched,the violation data of antibacterials was audited manually according to the specific meaning of the audit rules.（3）Using the method of segmented regression analysis of interrupted time series data,this study analyzed the impact of the audit rules related to the utilization of antibacterials in the Intelligent Audit of Medical Insurance in Wuhan on the utilization of antibacterials of inpatients from two aspects:level change and trend change.[Results]（1）There are two audit rules related to antibacterials in the Intelligent Audit of Medical Insurance in Wuhan,one is the limited indication（condition）drug use audit rule,the other is the ladder drug use audit rule.There were 12 kinds of illegal antibacterials involved in the two audit rules in the sample hospitals.It is found that there are seven kinds of antibacterials had violated the limited indication（condition）drug use audit rule,namely piperacillin tazobactam sodium（injection）,cefotaxime（injection）,vancomycin（injection）,norvancomycin（injection）,teicoplanin（injection）,voriconazole（injection）and voriconazole capsule.And there are five kinds of antibacterials had violated the ladder drug use audit rule,namely cefathiamidine（injection）,moxifloxacin（injection）,imipenem cilastatin（injection）,meropenem（injection）and etimicin（injection）.（2）In general,after the implementation of the Intelligent Audit of Medical Insurance,the rate of antibacterials violating the audit rules,the rate of antibacterials application（per thousand people）,DDDs/100 patient days of antibacterials involved in the limited indication（condition）drug audit rule were all decreased,and the submission rate of pathogenic samples before using these drugs was improved.The results of segmented regression analysis indicated that after the implementation of audit rule,the rate of antibacterials violating the audit rule immediately decreased by 12.10%（P<0.0001）,but compared with that before,the decline trend significantly decreased（β₃=0.64,P=0.002）;there was no instantaneous change or significant trend change in the rate of antimicrobials application（per thousand people）and DDDs/100 patient days;and the submission rate of pathogenic samples of patients using these drugs immediately increased by 6.01%（P=0.040）,but the change trend transformed from an upward trend to a downward trend.（3）In general,after the implementation of the Intelligent Audit of Medical Insurance,the rate of antibacterials violating the audit rules,the rate of antibacterials application（per thousand people）,DDDs/100 patient days of antibacterials involved in the ladder drug use audit rule were all decreased,and the submission rate of pathogenic samples before using these drugs was improved.The results of segmented regression analysis indicated that after the implementation of audit rule,the rate of antibacterials violating the audit rule immediately decreased by 28.14%（P<0.0001）,without significant trend change（β₃=-0.98,P=0.147）;the rate of antimicrobials application（per thousand people）immediately decreased by 33.20‰（P=0.001）,without significant trend change（β₃=-0.77,P=0.475）;DDDs/100 patient days immediately decreased by 1.31（P=0.009）,and there was also a significant trend change（β₃=-0.09,P=0.014）,which changed from increasing 0.05DDDs/100 patient days monthly to 0.04DDDs/100 patient days monthly;and the submission rate of pathogenic samples of patients using these drugs had no significant level change（β₂=-5.55,P=0.102）,and the upward trend was significantly was solwer than that before（β₃=-1.20,P<0.0001）.[Conclusions]（1）The Intelligent Audit of Medical Insurance in Wuhan promotes the rational use of antibacterials to a certain extent.（2）However,there are still some problems of the Intelligent Audit of Medical Insurance in Wuhan,including that the limited indications set in the limited indications（conditions）drug use audit rule are not completely consistent with the indications in the drug specification,which brings certain problems to doctors;the system of Intelligent Audit of Medical Insurance is not fully related to the Hospital Information System of the designated hospital,which makes the medical record information of patient cannot be fully obtained,resulting in a lot of audit work still needs to be done through artificial auditing after the event happened.（3）It is suggested that the medical insurance department should further improving the audit rules of medical insurance;improving the intelligent level of medical insurance intelligent audit,making the audit change from post-audit to pre-audit;and strengthening the publicity and education on the rules of medical insurance audit for clinicians.[Innovation and Limitation]The innovation of this study has two points as follows:（1）This study focused on the Audit of Medical Insurance,and analyzed the impact of the new management tools based on the perspective of medical insurance---the Intelligent Audit of Medical Insurance on the clinical application of antimicrobials through empirical research,which proved that medical insurance intelligent audit is an effective antimicrobials management tool.（2）In this study,segmental regression analysis was used to analyze the impact of Wuhan Medical Insurance Intelligent Audit on the utilization of antibacterials in the hospitalized patients.This method is one of the high-grade research methods except for randomized controlled trials（RCT）.The shortcomings of this study have three points as follows:（1）Only one top-level hospital was selected to analyze the impact of Intelligent Audit of Medical Insurance on the utilization of antibacterial drugs,the research results have insufficient scalability.（2）When calculating the rate of antibacterials violating the audit rules,the number of violation prompted by the Intelligent Audit of Medical Insurance system was used instead of the number of violation determined after hospital complaints and medical insurance center reconsideration,which may caused higher rate of antibacterials violating the audit rules.（3）During the study period,there were other measures related to antimicrobials implemented at the same time,which may affect the analysis of intervention effect.