Use of Essential Medicines for Diabetes in Different Levels of Hospitals during the Implementation of Hierarchical Medical System

doi:10.12114/j.issn.1007-9572.2021.00.028

Abstract

Abstract: Background　Due to increasing diabetes prevalence year by year，diabetic prevention and treatment have become extremely severe challenges to China，and the associated hierarchical diabetes management is a key part of the ongoing development of hierarchical diagnosis and treatment. Whether diabetes medication services in primary hospitals in which essential medicines make up the largest proportion of medicines can appropriately link up the diabetes medication services in higher level referral hospitals is an important issue that may directly affect the improvement of diabetes prevention and treatment ability and uniformity of diabetic treatments in primary hospitals. Objective　To study the connection of diabetes medication services in different levels of hospitals under the implementation of the hierarchical medical system，and to explore the impact of the implementation of the national essential medicine system on the supply guarantee system of drugs for chronic disease prevention and treatment. Methods　A total of 9 hospitals were selected from Zhejiang，Anhui，and Shaanxi provinces（a provincial tertiary hospital，a county secondary hospital，and a primary hospital were selected from each province）. Drug purchase data were collected from China Medical Economic Information Network of Chinese Pharmaceutical Association from 2016 to 2018. The connection of medication services among three levels of hospitals was studied by comparatively analyzing the forms，specifications，DDDs and costs of antidiabetic drugs and essential antidiabetic drugs and related trend of changes. Results　Overall，it was found that the forms and specifications of essential antidiabetic drugs accounted for 25.58%（33/129） of those of antidiabetic drugs in hospitals in these provinces，and the proportions of DDDs in hospitals of different levels in 2018 were significantly different（P<0.01）. The number of essential antidiabetic drugs of different forms and specifications in terms of DDDs listed in the top 10 was the most in Anhui's hospitals（7） and the least in Shaanxi's hospitals（3）．Comparisons by the level of hospital among provinces showed that the hospital of Anhui had the highest proportion of DDDs and costs of essential antidiabetic drugs（64.08% and 41.49%） at the tertiary level as well as at the primary level（38.11% and 28.77%）. Zhejiang's secondary hospital had the highest proportion of DDDs and costs of essential antidiabetic drugs（40.63% and 35.00%） among the three secondary hospitals. Compared with the three-year growth rate of drug use frequency and sum of money of essential drugs and non essential drugs in different levels of hospitals，except for the growth rate of drug use frequency in Shaanxi Province（P>0.05），the differences of other indicators were statistically significant in Zhejiang Province and Anhui Province（P<0.01）. Conclusion　Our study suggests that the use of antidiabetic drugs differed significantly by region as well as the level of hospitals，the connection of diabetic medication services among different levels of hospitals was unsatisfied，and the essential antidiabetic drugs in primary hospitals could not meet the needs of chronic disease patients，which need to improve urgently.

Key words: Hierarchical medical system, Diabetes, Essential medicines, Drug utilization, Chronic disease management, Zhejiang, Anhui, Shaanxi

摘要： 背景　我国糖尿病患病率逐年剧增，防治工作异常严峻，做好糖尿病防治管理是分级诊疗制度建设的重点任务。但是，基层医院以基本药物使用占绝对主导地位的药品供应保障体系，能否与其转诊的上级医院糖尿病用药对接是非常重要的环节，其直接影响基层糖尿病防治能力和同质化水平的提高。目的　研究分级诊疗制度下不同级别医院间糖尿病治疗药物衔接状况，探索基本药物制度的实施对慢性病防治药物保障体系的影响。方法　选择浙江、安徽、陕西省不同级别样本医院共9家，基于中国药学会全国医药经济信息网2016—2018年药品采购数据，通过对糖尿病治疗药物及基本药物使用品种结构、用药频度、金额等情况比较，分析变化趋势，研究不同级别医院间用药衔接状况。结果　3个省份基本药物品规数占糖尿病治疗药物总品规的25.58%（33/129），不同级别医院2018年用药频度占比比较，差异均有统计学意义（P<0.01）。基本药物进入用药频度前10位的品规数，以安徽省最多（占7种）、陕西省最少（占3种），用药频度和金额占比最高的分别是安徽省的三级医院（64.08%和41.49%）和基层医院（38.11%和28.77%）、浙江省的二级医院（40.63%和35.00%）。不同级别医院基本药物与非基本药物用药频度、用药金额3年增长率比较，除陕西省用药频度增长率差异无统计学意义（P>0.05）外，浙江省和安徽省其余各项指标比较差异均有统计学意义（P<0.01）。结论　糖尿病治疗药物利用情况在不同地区、不同级别医院存在较大差异，药物衔接状况较差，基本药物难以满足分级诊疗基层医院慢性病用药需求，亟须完善。

关键词: 分级诊疗, 糖尿病, 基本药物, 药物利用, 慢性病管理, 浙江, 安徽, 陕西

ZHANG Xiaomin,CHEN Xiang,CHEN Jiang, et al. Use of Essential Medicines for Diabetes in Different Levels of Hospitals during the Implementation of Hierarchical Medical System　[J]. Chinese General Practice, 2021, 24(12): 1546-1551. DOI: 10.12114/j.issn.1007-9572.2021.00.028.
章小敏,陈翔,陈将等. 分级诊疗制度下不同级别医院间糖尿病基本药物使用现状研究[J]. 中国全科医学, 2021, 24(12): 1546-1551. DOI: 10.12114/j.issn.1007-9572.2021.00.028.

References

［1］International Diabetes Federation．The 8th edition of the diabetes atlas．2017［EB/OL］．（2018-08-18）［2020-03-12］．http://www.diabetesatlas.org.
［2］WANG L，GAO P，ZHANG M，et al．Prevalence and ethnic pattern of diabetes and prediabetes in China in 2013［J］．JAMA，2017，317（24）：2515-2523．DOI：10.1001/jama.2017.7596.
［3］原国家卫生计生委办公厅，国家中医药管理局办公室．关于做好高血压、糖尿病分级诊疗试点工作的通知［EB/OL］．（2015-12-01）［2020-02-12］．http://www.satcm.gov.cn/yizhengsi/gongzuodongtai/2018-03-24/2700.html.
［4］国家卫生健康委员会，国家中医药管理局．关于进一步做好分级诊疗制度建设有关重点工作的通知［EB/OL］．（2018-08-20）［2020-02-12］．http://www.gov.cn/xinwen/2018-08/20/content_5315056.htm.
［5］董文兰，娄青林，吴蕾，等．社区2 型糖尿病患者直接经济负担及其相关因素分析［J］．中国公共卫生，2019，35（11）：1457-1460．DOI：10.11847/zgggws1120571.
DONG W L，LOU Q L，WU L，et al．Direct economic burden of type 2 diabetes mellitus and its influencing factors among community patients［J］．Chin J Public Health，2019，35（11）：1457-1460．DOI：10.11847/zgggws1120571.
［6］马旭，赵林华，马琳，等．中国糖尿病防治相关指南基层推广现状分析［J］．社区医学杂志，2019，17（19）：1167-1170． DOI：10.19790/j.cnki.JCM.2019.19.01.
MA X，ZHAO L H，MA L，et al．Current status of popularization and application of relevant guidelines for diabetes prevention and treatment in China at grass-roots level［J］．J Community Med，2019，17（19）：1167-1170．DOI：10.19790/j.cnki.JCM.2019.19.01．
［7］蔡淳．遵循指南规范实践《国家基层糖尿病防治管理指南（2018）》管理基本要求部分解读［J］．中华内科杂志，2019，58（2）：147-149．DOI：10.3760/cma.j.issn.0578-1426.2019.02.013.
CAI C．Interpretation of the management requirements of national guidelines for the prevention and control of diabetes in primary care（2018）［J］．Chin J Intern Med，2019，58（2）：147-149．DOI：10.3760/cma.j.issn.0578-1426.2019.02.013.
［8］中华医学会糖尿病学分会，国家基层糖尿病防治管理办公室．国家基层糖尿病防治管理指南（2018）［J］．中华内科杂志，2018，57（12）：885?893．DOI：10.3760/cma.j.issn.0578-1426.2018.12.003.
Chinese Diabetes Society，National Office for Primary Diabetes Care．National guidelines for the prevention and control of diabetes in primary care（2018）［J］．Chin J Intern Med，2018，57（12）：885?893．DOI：10.3760/ cma.j.issn.0578-1426.2018.12.003.
［9］顾天伟，朱大龙．综合管理合理用药——《国家基层糖尿病防治管理指南（2018）》治疗部分解读［J］．中华内科杂志，2019，58（7）：538-540．DOI：10.3760/cma.j.issn.0578 1426.2019.07.011.
GU T W，ZHU D L．Interpretation of treatment part of national guideline for the prevention and control of diabetes in primary care（2018）［J］．Chin J Intern Med，2019，58（7）：538-540．DOI：10.3760/cma.j.issn.0578 1426.2019.07.011.
［10］张敏，李建香，马文静，等．我国糖尿病流行病学和疾病经济负担研究现状［J］．世界最新医学信息文摘，2017（56）：183．DOI：10.3969/j.issn.1671-3141.2017.56.147.
ZHANG M，LI J X，MA W J，et al．Research status of diabetes epidemiology and disease economic burden in China［J］．World Latest Medicne Information，2017（56）：183．DOI：10.3969/j.issn.1671-3141.2017.56.147.
［11］郭凯，张春燕，钱敏，等．糖尿病区域卫生协同发展管理模式在糖尿病患者管理中的应用效果研究［J］．中国全科医学，2019，22（33）：4099-4104．DOI：10.12114/j.issn.1007-9572.2019.00.327.
GUO K，ZHANG C Y，QIAN M，et al．Application effect of regional collaborative diabetic healthcare management model in diabetic patients［J］．Chinese General Practice，2019，22（33）：4099-4104．DOI：10.12114/j.issn.1007-9572.2019.00.327.
［12］蔡淳，程旻娜，贾伟平．糖尿病分级诊疗和全程健康管理服务的策略与实践［J］．中华糖尿病杂志，2018，10（12）：765-768．DOI：10．3760/cma.j.issn.1674-5809.2018.12.002.
CAI C，CHENG M N，JIA W P．Strategies and practice of diabetes hierarchical diagnosis and treatment system and whole-course health management services［J］．Chin J Diabetes Mellitus，2018，10（12）：765-768．DOI：10.3760/cma.j.issn.1674-5809.2018.12.002.
［13］杨森，王朝昕，金花，等．基于利益相关者的上海市分级诊疗现状系统评价［J］．中国全科医学，2018，21（22）：2672-2678．DOI：10.12114/j.issn.1007-9572.2018.22.006.
YANG S，WANG Z X，JIN H，et al．Assessment of the implementation of hierarchical medical system in Shanghai from a multi-stakeholder perspective：a systematic review［J］．Chinese General Practice，2018，21（22）：2672-2678．DOI：10.12114/j.issn.1007-9572.2018.22.006.
［14］林璐，史俊隆，顾婷，等．以分级诊疗为导向的三级医院门诊糖尿病患者分类研究［J］．中国医院，2018，22（11）：31-33．DOI：10.19660/j.issn.1671-0592.2018.11.09.
LIN L，SHI J L，GU T，et al．Diabetes outpatient patient classification analysis in tertiary hospital based on hierarchical healthcare system［J］．Chinese Hospitals，2018，22（11）：31-33．DOI：10.19660/j.issn.1671-0592.2018.11.09.
［15］李莹，陈中建．上海地区22家医院2013—2015年带状疱疹患者药物应用分析［J］．中国药房，2017，28（8）：1037-1040．DOI：10.6039/j.issn.1001-0408.2017.08.08.
LI Y，CHEN Z J．Analysis of drug utilization in herpes zoster patients from 22 hospitals of Shanghai area during 2013—2015［J］．China Pharmacy，2017，28（8）：1037-1040．DOI：10.6039/j.issn.1001-0408.2017.08.08.
［16］章小敏，陈将，陈翔，等．分级诊疗与不同级别医院间药品使用研究［J］．医院管理论坛，2019，36（9）：20-23．DOI：10.3969/j.issn.1671-9069.2019.09.005.
ZHANG X M，CHEN J，CHEN X，et al．Study on hierarchical medical service and drug use among hospitals of different levels［J］．Hospital Management Forum，2019，36（9）：20-23．DOI：10.3969/j.issn.1671-9069.2019.09.005．
［17］侯延武，怀国尹，庞秀明．国家基本药物制度与医药卫生体制改革的协同与评述［J］．黑龙江医学，2018，42（7）：710-714．DOI：10.3969 /j.issn.1004-5775.2018.07.034.
HOU Y W，HUAI G Y，PANG X M．Synergy and review of National Essential Medicine System and Medical and Health System reform［J］．Heilongjiang Medical Journal，2018，42（7）：710-714．DOI：10.3969 /j.issn.1004-5775.2018.07.034.
［18］孔颖文，曹杰，郑艳芳，等．基于利益相关者理论的双向转诊“下转难”研究［J］．中国全科医学，2017，20（10）：1173-1176．DOI：10.3969/j.issn.1007-9572.2017.10.006.
KONG Y W，CAO J，ZHENG Y F，et al．"Down-referral being difficult" phenomenon in the two-way referral based on stakeholder theory［J］．Chinese General Practice，2017，20（10）：1173-1176．DOI：10.3969/j.issn.1007-9572.2017.10.006.
［19］国家卫生健康委员会，国家中医药管理局．关于进一步加强公立医疗机构基本药物配备使用管理的通知［EB/OL］．（2019-01-10）［2020-02-12］．http://www.gov.cn/gongbao/content/2019/content_5395490.htm9.
［20］张闪闪，吴天，张冉，等．2018年版《国家基本药物目录》调整解读［J］．卫生经济研究，2019，36（6）：47-50．DOI：10.14055/j.cnki.33-1056/f.2019.06.013.
ZHANG S S，WU T，ZHANG R，et al．Interpretation of the 2018 Edition of the National Essential Drugs List［J］．Health Economics Research，2019，36（6）：47-50．DOI：10.14055/j.cnki.33-1056/f.2019.06.013.
［21］CHING C E，UENG K C，CHAO T H，et al．2020 Consensus of Taiwan Society of Cardiology on the pharmacological management of patients with type 2 diabetes and cardiovascular diseases［J］．J Chin Med Assoc，2020，83（7）：587-621．DOI：10.1097/JCMA.0000000000000359.

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