Đánh giá thực trạng kê đơn và chăm sóc bệnh nhân điều trị ngoại trú bảo hiểm y tế tại một số cơ sở y tế công lập ở thành phố cần thơ giai đoạn 2016 2018 tt tiếng anh

MINISTRY OF MILITARY MILITARY MEDICAL UNIVERSITY HUNG NGUYEN PHUC ASSESSMENT OF PRESCRIPTION AND CARE FOR OUTPATIENTS WITH HEALTH INSURANCE AT SOME PUBLIC HEALTHCARE FACILITIES IN CAN T

MINISTRY OF MILITARY

MILITARY MEDICAL UNIVERSITY

HUNG NGUYEN PHUC

ASSESSMENT OF PRESCRIPTION AND CARE FOR OUTPATIENTS WITH HEALTH INSURANCE

AT SOME PUBLIC HEALTHCARE FACILITIES

IN CAN THO CITY IN THE PERIOD OF 2016-2018

Major: Pharmaceutical management organization

Code: 9 72 02 12

SUMMARY OF PHARMACEUTICAL Ph.D THESIS

HA NOI – 2020

MILITARY MEDICAL UNIVERSITY

Scientific supervisors:

1 Assoc.Prof Chinh Nguyen Minh

Reviewer 1: Assoc.Prof Vu Hoang Thy Nhac

Reviewer 2: PhD My Nguyen Huu

Reviewer 3: Prof Binh Nguyen Thanh

The Thesis will be defended against the Council of Military Medical University at: o’clock day month year

This thesis can be referred at:

1 National Library of Vietnam

2 Library of Military Medical University

INTRODUCTION

Drugs have an important role in the disease treatments, but they have various side effects In case of incorrect use, it will cause bad consequences that directly affect human health such as prolonging treatment time, increasing the death rate of patients, increasing the cost of treatment, especially increasing the drug dependence in general and antibiotic resistance in particular Statistically, more than 50% of drugs are used improperly worldwide In 1985, the World Health Organization held a large conference in Nairobi - Kenya on rational use of drugs and developed drug use indicators

In Vietnam, the situation of prescription is not out of the general trend of developing countries, which is the abuse of antibiotics, injections, vitamins, prescribing too many drugs in a prescription In addition, in the past time, some medical facilities have not paid adequate attention to the conditions to serve patients and improve the quality of medical examination and treatment; and the quality of health services organization does not commensurate with the cost

At the public health facilities in Can Tho receiving medical examination and treatment with health insurance in 2015, about 6,351 outpatients visited the hospital per day and 97% of them had health insurance cards Therefore, the work of prescribing medical examination and care for patients with health insurance at the hospital should be more closely monitored From the above practices,

the topic: "Assessment of virtual prescription and care for outpatient with health insurance at some public healthcare facilities in Can Tho city in the period of 2016-2018" has been

done with the following goals:

1 Assess the status of prescription and the effectiveness of some interventions in prescribing outpatient health insurance drugs at

some public health facilities in Can Tho city for the period

2016-2018

2 Assess the situation of patient care and the effectiveness of some interventions in the care of patients with outpatient health insurance at some public health facilities in Can Tho city in the period of 2016-2018

New contributions of the thesis:

The study was conducted to fully evaluate the prescribing activities of physicians through evaluating the implementation of the prescription regulations and comprehensive indicators, and at the same time assess the satisfaction of the people about the health facility

The study compared the effectiveness of some interventions at 3 healthcare facilities, which serves as a basis for broad deployment of the solutions from the experience at these 3 facilities in Can Tho City, the largest and most developed city in the Mekong Delta with a large number of medical examinations and treatment facilities (11 facilities) Thus, the research results will be representative and has scientific value

The layout of the thesis:

The content of the thesis is presented in 146 pages, including 4 chapters: Introduction: 2 pages; Chapter 1 - Overview: 34 pages; Chapter 2 - Subjects and research methods: 25 pages; Chapter 3 - Research results: 42 pages; Chapter 4 - Discussion: 40 pages; Conclusion: 2 pages; Recommendations: 1 page The thesis includes:

54 tables, 7 diagrams, and 120 references

Chapter 1

OVERVIEW 1.1 Rules of prescriptions for outpatient treatment, indicators of drug use, the factors affecting drug use

1.1.1 Rules of prescriptions for outpatient treatment

According to Article 6 of Circular No 05/2016 / TT-BYT of the Ministry of Health, general requirements for prescription drug contain:

* Complete, clear and correct writing of the items that are printed on the prescription

* Exact written address of permanent or temporary residence

* For children under 72 months of age, the number of months and the name of the father must be recorded

* Write down the drug names according to the international generic name, except for drugs containing many active ingredients In case of additional drug names according to trade names, trade names must be put in parentheses after the international nonproprietary name

* Note the drug name, concentration / content, quantity, dose, route of administration, time of use of each drug

* Number of addictive drugs must be written in letters and the first letters are capitalized

* Number of medicine: write the number 0 beforehand if the number only has one digit (less than 10)

* In case of amendment of the application, the prescriber must sign next to the corrected content

* Cross the blank paper from the bottom of the prescription contents to the signature of the prescriber; Sign, write (or stamp) the full name of the prescriber

1.1.2 Indicators of drug use

1.1.2.1 Objective

Studies to assess the use of drugs will vary widely from place to place, depending on many factors such as the specific information needs of health managers, the type of record keeping system available on-site, service providers with the described routines, resources to conduct research In general, drug use studies are based

on indicators that fall into the following four broad groups:

* Description of prescription practice

* Comparing the implementation of drug use indicators between health facilities or prescribers or between health care groups

* Supervise and monitor each specific period of the year on drug use habits

* Evaluation of intervention effectiveness

1.1.3 Factors affecting drug use

1.1.3.1 According to the World Health Organization

* Simple, short-term training strategies are often ineffective and their effects are not sustainable

* Using printed materials is usually not effective

* Cooperation strategies, especially various strategies such as training combined with management often give better results

* Workshops focused on small groups and face-to-face discussions have proven to be effective, especially with competent trainers and coordinators

* Monitoring, feedback and evaluation are very effective strategies, but it requires consistency in the use of certain standards to evaluate prescription (e.g standard treatment guidelines)

* The reward bracket is an effective way of changing behavior; however, there are disadvantages that can lead to undesirable behaviors and promote inappropriate use of drugs

* Legal interventions may have an adverse effect worse than originally anticipated (e.g replacing prohibited drugs with inappropriate drugs)

1.1.3.2 According to the US Center for Medical Management Science (MSH: Management Sciences for Health)

Many factors affect drug use: the health system; prescriber; medicine dispensers; patients and the community MSH recommends intervention strategies to improve drug use: education strategy;

Management strategy; economic strategy; regulatory strategy

1.2.4 Summary of several studies on patient prescription and care in the world and in Vietnam

* Limitations of the topics:

+ Studies are cross-sectional studies, so the results are representative for one time of the year, not completely representative

of the establishment's use of drugs in the most comprehensive way + Limited mention of possible interventions as well as recommendations to the state management agencies for monitoring and evaluating

+ The sample size of the studies is quite small, so the indexes are not fully evaluated

+ Studies in Vietnam are often conducted at one healthcare facility, so it has not appreciated the situation of drug use when comparing between different health facilities or between different areas at the same time Therefore, the results of some studies do not represent an entire region or country

+ A number of studies were conducted at a third-class hospital and therefore it is necessary to further study these parameters at the central level

+ Studies have investigated the economic aspects of drug use However, they have not assessed the relationship between rational safety and economy

+ Researchers have not comprehensively assessed the causes of rational and safe use of drugs Overcrowding in healthcare facilities requires assessments and solutions

+ Interventions and supervision in drug use have not been thoroughly implemented Researchers have not boldly intervened and impacted the prescription system of drug use Research is therefore limited to warning levels for healthcare regulators

* Regarding the research scope:

+ The problem that needs to be researched and resolved here is: How do medical examination and treatment facilities operate, comply with the regulations and guidelines, and effectively affect the prescription and how to dispense drugs by healthcare workers through information and counseling activities on drug use

+ The medicine and treatment council has not been promoted in hospitals, most of the activities are still faint and of a coping nature, have not gone into analyzing the use and dispensing of drugs in hospitals to propose remedies No studies have analyzed the interventions on the activities of the hospital medicines and treatment Council and then re-evaluate the indicators of drug use as well as rational use of drugs

+ The main research topics on the subject are doctors, pharmacists, while not evaluating and analyzing prescription

* Outpatient health insurance prescriptions during the study period

2.1.1 Patient selection criteria

* Public health facilities with health insurance holders; patients and their relatives agree to participate in the study and fully answer questions in the interview

* Outpatient prescription with health insurance who encountered common disease in the community

2.1.2 Exclusion criteria

* Medical facilities, doctors at examination departments, pharmacists dispensing drugs, patients and/or their family members disagree to participate in the study

* Patients who come for outpatient examination but are transferred inpatient or emergency at a hospital

2.2 Methods

2.2.1 Research designs

* Direct observation of prescription and dispensing activities

* Direct interview of patients

* Descriptive method with analysis before - after intervention

2.2.2 Sample sizes

Based on the guidelines on survey of drug used index of WHO, for each healthcare facility, at least 100 prescriptions were chosen, according to the 2015-statistical table of Can Tho Social Insurance Can Tho University of Medicine and Pharmacy Hospital had the lowest average number of daily outpatient visited, thus the sample size wes 100 prescriptions According to the corresponding ratio, the number of prescriptions and insurance patients to be interviewed at each facility is as follow:

Table 2.2 The number of samples to be divided according to

11 healthcare facilities

No Healthcare Facilities No of

prescriptions

No of patients

2.2.4 Research content

2.2.4.1 Prescribing state in outpatient treatment with health insurance at some public healthcare facilities in Can Tho city in the

period of 2016-2017

* Determining prescriptions to comply with the Minister of

Health's prescriptions for outpatient treatment

* Prescription indicators: average number of prescriptions per one prescription, percentage of drugs prescribed by generic or international generic names (except for multi-ingredient medicines

that can be prescribed under trade names), the proportion of prescriptions with antibiotics, injectable drugs, vitamins, corticosteroids, the proportion of prescription drugs included in the list of essential drugs and the list of mainly drugs issued by the

MOH, and the proportion of drug interactions

* Comprehensive drug use indicators: the average cost for each prescription, ratio of antibiotics cost, ratio of injection cost, ratio of vitamin cost, ratio of corticosteroids cost, prescription rates consistent with the treatment regimen

* Survey the validity of outpatient prescription practice:

The rationality in the practice of prescribing drugs is built according to the definition in chapter 27.2 of the US Center for Management of Health Sciences: reasonable indications, reasonable doses (correct prescription dosage: single dose, 24-hour dose and divided into the correct number of times – based on the medication guide or the drug information online), reasonable route (based on the medication guide or research online information about drugs), appropriate treatment duration (not more than 30 days), reasonable information for patients (full prescription information on instructions for use, dosage, special notes)

2.2.4.2 Evaluate the effectiveness of some interventions in prescribing outpatient treatment with health insurance at some public healthcare facilities in Can Tho city

* Interventions: educational solutions, enhancing knowledge and promoting the rational dispensing of drugs

2.2.4.3 Evaluate the effectiveness of some interventions in prescribing and taking care of outpatient at some public healthcare facilities in Can Tho city

* 3 healthcare facilities: Can Tho university of Medicine and Pharmacy hospital, O Mon district general hospital, Phong Dien healthcare center

* Subjects of intervention: council of medicines and treatment, doctors prescribing outpatient drugs, pharmacists dispensing drugs for outpatient treatment of health insurance

* Observe the intervention solutions of state management agencies in charge of health at 3 establishments

* Assessing after intervetion: using T-test and Chi-square test to compare differences of before intervetion and after intervetion

2.2.4.4 Evaluate the effectiveness of some interventional solutions in caring for outpatients who have health insurance at some public healthcare facilities in Can Tho city

* Interventions: educational solutions, enhancing knowledge and promoting the rational dispensing of drugs

* Evaluation of SCT:

Review the status of patient care: patient care index, patient satisfaction with outpatient services have not been achieved at 3 healthcare facilities

2.2.5 Methods of processing and analyzing data

Data were processed using SPSS 20.0 software

Chapter 3

RESULTS 3.1 Results of assessing the status of prescription and the effectiveness of some interventions in prescribing outpatient

health insurance drugs at some public health facilities in Can Tho city in the period of 2016- 2018

3.1.1 Results of assessing the situation of prescribing for outpatient health insurance at some public health facilities in Can Tho city in the period of 2016-2017

3.1.1.1 Survey results on compliance with outpatient prescriptions

* Regarding compliance with administrative procedures regulations: the implementation of the provisions on administrative procedures needed in a prescription is quite well implemented (4/5 requests reach 100%), although there are still errors in recording patient's home address, only reaching average overall 88.3%, the error is usually due to missing address details or sometimes writing the name of the patient's work agency

* Regarding the compliance with the prescriptions: the percentage of correct implementation of regulations on compulsory contents in a prescription: 89.8% have correct full contents of the prescription, 96% have correct number of medicines

3.1.1.2 Assessment results in prescription index

* The average number of prescription drugs in a single prescription: The average for all survey samples is 5.00

* The proportion of drugs prescribed by the generic name and international common name: Cai Rang district general hospital is the only facility that does not achieve absolute success with 85.32% In which, 3 most pharmaceuticals were listed without the active ingredient names are Apitim (amlodipine) (12.55%), Domitral (nitroglycerin) (11.63%), and Detracyl (mephenesin) (6.36%)

* The proportion of applications with antibiotics: The average number of applications with antibiotics is 31.1% Antibiotics was initially selected for the treatment of gastrointestinal, respiratory, urology, mainly the β-lactam group