基于复杂网络分析探索药师在疾病诊断相关分组付费中的参与作用——以脑梗死临床路径用药方案优化为例

Participation role of pharmacists in DRGs payment based upon complex network analysis:optimization medication regimens of cerebral infarction clinical pathway as an example

目的:基于真实世界研究,提取医院信息管理系统(Hospital Information System,HIS)医疗电子病历,按照脑梗死临床路径探索神经内科医师药物开嘱习惯和模式,按照疾病诊断相关分组DRGs付费要求,优化子群网络中的药物经济性、用药合理性,为脑梗死疾病在DRGs付费下的合理用药提供依据。方法:从南昌大学第一附属医院2017年1月至2021年4月HIS医疗电子病历数据中,提取脑梗死患者医疗电子病历13588例,其中入组了脑梗死临床路径的为12501例,对脑梗死患者的合并用药进行复杂网络分析,并根据树形图提取子群网络进行用药优化分析。结果:复杂网络分析共纳入100种入组临床路径后常用药物,对药物复杂关系网络进行划分,得到3个主要的用药子群。对其中药物连接度占比较高的子群2进行优化分析,其中包括阿司匹林肠溶片、氢氯吡格雷片、阿托伐他汀钙片、瑞舒伐他汀钙片、依达拉奉注射液、单唾液酸四己糖神经节苷脂等16种药物,初始用药费用为8846元。从医保和药物经济学角度考虑将盐酸罂粟碱氯化钠注射液替换为盐酸罂粟碱注射液,并同种适应证的药物选择一种,天麻素注射液需要有头晕的诊断才可以使用。经过与医师沟通,预计子群2中的16种药物可组成多个治疗方案,其中最优化的用药方案10日费用约为1642元,达到用药优化目的,且用药合理性提高。结论:用药子群是代表医师的用药习惯,通过用药合理性、药物经济性评价、医保支付角度,优化脑梗临床路径的经济方案,降低路径治疗费用并提高合理性。继续对其他子群的优化,可以降低脑梗死临床路径费用,使得医疗机构和医师可以享受到药师参与的临床路径下DRGs付费的改革成果。

OBJECTIVE Based upon a real world study,medical electronic record data were extracted from hospital information system(HIS)for exploring the clinical medication prescription habits and patterns according to cerebral infraction clinical pathway.According to the physician's prescription patterns and the payment requirements of(diagnosis related groups)DRGs,drug economy and rationality in the complex network subgroups were optimized to provide references for rational drug use of cerebral infarction under DRGs payment.METHODS From January 2017 to April 2021,13,588/12,501 cases of cerebral infarction were enrolled into clinical pathway of cerebral infarction.Complex network analysis was performed for the combination of drug use and subgroup network extracted via tree diagram for drug use optimization.RESULTS A total of 100 commonly used drugs were included for complex network analysis and three major drug subgroups obtained by extracting subgroups.Subgroup 2 with the highest drug connectivity was optimized,including aspirin enteric coated tablets,hydrocclopidogrel tablets,atorvastatin calcium tablets,rosuvastatin calcium tablets,edaravone injection,monosialotetrahexosylganglioside,etc.For 16 kinds of drugs,initial expenditure or subgroup was 8,846 yuan.From the perspectives of medical insurance and pharmacoeconomics,papaverine hydrochloride sodium chloride injection should be replaced by papaverine hydrochloride injection and only one drug with the same indication could be selected.Gastrodin injection was indicated for dizziness after an auxiliary diagnosis.After communication and optimization with physicians,it was estimated that 16 drugs in subgroup 2 could form multiple treatment schemes according to different mechanisms.The expenditure of optimal scheme was around 1,642 yuan per 10 days so as to achieve the purpose of drug optimization and improve the rationality of drug use.CONCLUSION The major extracted medication subgroup represents the medication habits of physicians.From the perspective of drug rationality,drug economic evaluation,medical insurance,economic scheme of clinical pathway of cerebral infarction may be optimized to the greatest extent.While the expenditure of pathway treatment may be reduced and the rationality of pathway medication improved for a maximal efficacy of functional drugs plus therapeutic agents.Optimizing the network of other subgroups may lower the overall expenditure of cerebral infarction clinical pathway so that medical institutions and physicians may share the reform results of DRGs payment under the participation role of pharmacists.