上海市药物使用联动机制对医疗机构门诊服务利用结构的影响：基于中断时间序列模型

Impact of Collaborative Drug Therapy Management Mechanism on the Utilization Structure of Outpatient Care in Medical Institutions in Shanghai,China:an Interrupted Time Series Analysis

背景为吸引居民签约,满足居民个性化的用药需求,上海市卫生健康委员会在国家基本药物制度基础上,对经家庭医生转诊至上级医院的签约居民,如其确需延续上级医院用药医嘱,在回到签约家庭医生处就诊时,家庭医生可根据上级医院用药医嘱开具相同药品(麻醉药品和精神药品除外。形成“基本+补充”的药品使用联动机制,简称延伸处方政策)。其目的是提高居民在社区卫生服务中心配药的便捷度,减轻上级医院门诊配药负荷、居民和医保基金的经济负担。目的探索延伸处方政策对各级医疗机构门诊服务利用结构的影响。方法通过上海市社区信息化平台(上海市社区卫生综合改革云管理平台),选取2015年1月—2017年12月上海市243家社区卫生服务中心签约高血压患者在延伸处方政策实施前后(2016-2017年)的相关数据〔产出指标(延伸处方数量、延伸处方金额、患者病种、药物配送成功率、配送周期)和结果指标(医院和社区卫生服务中心就诊次数、医疗费用、处方数量、药物费用)〕。以2017年1月为政策干预点,运用中断时间序列模型(ITS)分析实施延伸处方政策后结果指标的变化趋势。结果2016—2017年延伸处方数量上升明显,截至2017年底,延伸处方数量累计总数超过90万张,延伸处方累计金额已超过1.9亿元。开具延伸处方患者多为慢性病,共45个病种。大部分药物配送成功率均超过90.00%,配送周期除政策初期(2016年1—3月)配送时间较长外,其余配送周期基本控制在5d以内。二、三级医院高血压患者就诊次数、医疗费用、处方数量和药物费用均有下降趋势(代表斜率变化的β3的P值均<0.05)。社区卫生服务中心高血压患者就诊次数、医疗费用、处方数量和药物费用改革前后的趋势变化无统计学意义(代表斜率变化的β3的P值均>0.05)。结论 根据阶段性评估结果以及签约居民多样的实际用药需求,延伸处方政策的实施能够减轻二、三级医院的慢性病患者就诊压力,有其继续存在和推广价值;建议继续作为引导签约居民主动利用家庭医生提供诊疗服务的激励措施之一,用于满足社区居民的合理用药需求,引导科学就医,优化诊疗秩序。

Background In order to attract residents to sign a health service contract with the family doctor,and satisfy their individualized medication needs,on the basis of the National Essential Drug System,Shanghai Municipality Health Commission issued the extended prescription policy,which means that family doctors can prescribe the same drugs(except narcotic drugs and psychotropic substances)prescribed by a higher level medical institution for their contracted residents with the experience of being transferred upward via their appointment if the residents need to use the drugs continually.In this way,a collaborative drug therapy management mechanism of"basic therapy+supplementary therapy"is developed,which aims to improve the convenience of dispensing drugs in the community health center(CHC),reduce the dispensing workload in the clinic of higher level hospitals,and decrease the economic burden of residents and medical insurance funds.Objective The aim of this study was to estimate the impact of collaborative drug therapy management mechanism on the utilization structure of outpatient care in different levels of medical institutions.Methods From Shanghai Community Informatization Platform(Shanghai Community Health Comprehensive Reform Cloud Management Platform),we collected two-year(2016-2017,the period before and after the implementation of extended prescription policy)healthcare data(output indicators included cumulative number of extended prescriptions,cumulative costs of the extended prescribed drugs,types of diseases,successful rate and cycle of dispensing,and outcome indicators included visits in hospitals and CHCs,healthcare costs,number of prescriptions,and costs of drugs)of contracted hypertensive patients who received healthcare services from 243 CHCs in Shanghai during January 2015 to December 2017.Interrupted time series model(ITS)was used to analyze the change trend of aforementioned indictors after(January 2017 was defined as the intervention timing of related policies)the implementation of policy.Results The number of extended prescriptions showed a fast increase between 2016 and 2017.By the end of 2017,the cumulative number of extended prescriptions was more than 0.9 million,and the cumulative costs of extended prescribed drugs were over 19 million yuan.Most extended prescriptions were written for managing chronic diseases,involving a total of 45 types.Most(over 90.00%)drugs were dispensed successfully.The dispensing cycles of all drugs were implemented within 5 days basically,except that the cycles were longer in the initial stage of implementation(from January to March 2016)of the policy.Compared with before the implementation of the policies,after the policy intervention,the number of visits,number of prescriptions,therapeutic and treatment costs and costs of medicines for hypertensive patients in secondary and tertiary hospitals showed a downward trend(P value ofβ3 representing the slope change was less than 0.05).However,the number of visits,number of prescribing,average cost of per consultation,and average cost of prescribed drugs per visit in CHCs showed no significant changes(P value ofβ3 representing the slope change was greater than 0.05).Conclusion Phased evaluation results of the implementation of extended prescription policy and contracted residents'multiple needs of pharmacological treatment show that the implementation of the policy could relieve the stress of secondary and tertiary hospitals in addressing challenges of great number of chronic disease visits,so it can be implemented continuously and be promoted further,and is suggested to be used as an incentive for guiding contracted residents in actively utilizing family doctors services,as a measure for satisfying the rational needs of pharmacological treatment in community-dwelling residents,and for optimizing the order of diagnosis and treatment via guiding residents'seeking healthcare in a scientific way.