基本药物遴选的方法研究
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摘要
[背景]在“新医改”的推动下,2009年8月,中国颁布了第一版基层使用的《国家基本药物目录》并配套了较为完整的国家药物政策,试图通过建立基本药物制度解决人民看病药费高、买药难的问题。2009年至2011年,是中国初步建立基本药物制度的三年。基本药物的遴选,主要是制定出《基本药物目录》,基本药物后续的生产、供应、使用、报销、临床指南和合理用药都依赖于基本药物目录。然而,关于基本药物的遴选,国内外主要局限于专家主观决策,而定量、客观的遴选方法较少。我国未来每三年修订一次国家基本药物目录的工作计划,也要求遴选方法不断改进、丰富。
     国际上,许多国家都拥有《国家基本药物目录》,尤其是发展中国家。因为各国经济、发展目标、卫生保障系统的药品筹资能力、新药的不断产生、疾病谱等的变化,药物政策也需要随之调整、变化、优化。《世界卫生组织基本药物示范目录》主要是由世界卫生组织的基本药物专家委员会来制定,专家由临床专科医生、药师、卫生管理者、卫生经济学者、卫生政策官员等组成,通过开会讨论的方式产生各版“示范”目录。
     而国内,遴选基本药物的方法,是靠建立专家信息库并咨询专家和通过投票的形式产生目录初稿的。我国现行方法,也是一种主要靠经验决策的专家法。缺乏对各种遴选方法的系统总结和比较研究,也缺乏遴选操作的方法指南,创新的方法也不多。
     [目的]
     为了我国更好的实施国家药物政策、全面推广基本药物制度,这篇论文旨在系统总结基本药物遴选的各种方法:以便为现行主观遴选的决策方法补充更加定量的、客观的方法;并对各种不同的遴选方法进行综合地比较、系统地评价,以便为未来我国基本药物目录的更新、基本药物增补目录的制定和更新,提供更多的方法选择;并根据每种方法的各自特点,为卫生政策制定者在遴选基本药物、更新基本药物目录时提供有针对性的决策参考。
     总目标:是能够为卫生政策制定者、卫生管理决策者,在遴选药物和制定各种基本药物目录的时候,能够有“法”可依、有“法”可选。
     分目标:其一,是针对现行方法缺乏总结、缺少操作指南的研究“盲”点,对现行遴选方法更加深入、系统地研究,达到“改进方法”的目的;其二,虽然世界卫生组织和我国都提出用循证评价和药物经济学方法弥补现行专家法的不足,在方法操作上却存在研究“难”点,需要解决如何把循证医学的原理应用于药物的遴选和评价的难点,并需要解决药物经济学如何操作和应用于遴选的难点,达到能够为遴选决策“补充方法”的目的;其三,针对以上四种方法的“缺”点,能否创造出更新的的方法,能够更加客观、定量、优化、统筹地遴选药物呢?这就需要“创新方法”;其四,这许多遴选方法,那一个的综合效果最好呢?遴选的精髓是什么?尤其是在不同的国情和卫生政策“重”点下,该如何选择何种方法呢?对各种方法进行定量评分和定性评价,以便使卫生决策者不仅有更多的选择、也可以更优的选择,达到能够辅助其“选择方法”的目的。[方法]
     根据公共管理学、卫生管理学、循证医学、社会医学、药物经济学、管理运筹学、药物政策学等的基础理论,系统总结(包括创新背包模型方法)六种基本药物的遴选方法,并在对各种方法进行比较的时候,运用了定量评分和模糊综合评价等定量评价方法,也应用了SWOT分析等定性评价方法。定量为主、定性为辅,是本文方法研究的一个主要特点。
     定量的研究方法,如循证医学方法、药物经济方法、层次分析方法、背包模型方法、灰色关联法等,在本文使用的较多。循证医学方法,应用于基本药物的遴选,主要是根据医学的客观实验数据和结果,来评价药物的疾病治疗效果。药物经济方法,应用于基本药物的遴选,主要是根据最小成本-效果目标,量化药物价格等因素与药物治疗效果的比值,遴选低成本、高疗效的药物。层次分析法,可以计算出各待选方案的综合评分并排序,是定量和定性为主的方法。定量之处主要是指标的计算和层次一致性的检验;定性之处,主要是判断矩阵的主观设计,定量和定性结合的方法,但是在基本药物的遴选方面,定量的计算数据量庞大。背包模型方法,是一种数学规划模型方法,在管理科学中应用不少,但是在药物遴选问题中的应用还没有,其求解算法非常复杂,但是可以由计算机辅助完成。灰色关联法,主要用于在指标体系不系统、指标权重不明晰等模糊信息条件下,对备选方案进行内部的比较和综合评价的一种方法
     定性的研究方法,本文使用的主要是专家法、文献法、现场调查法、网络信息检索等。专家法的研究,主要是研究如何应用于基本药物的遴选。文献法、现场调研、网络检索等,主要为课题的研究提供必备的数据来源。
     理论结合实践,是本文的另一大特色。对上述各种遴选的理论方法,本研究还组织了课题组,进行遴选的实战研究,通过在实践中应用和示范遴选的方法,能够更加完整、完善地总结和评价各种理论方法。[结果]
     以青霉素类药品的遴选为例,对六种方法的遴选做了示范,形成了多种药物组合方案,即不同的基本药物目录方案结果。
     根据青霉素类药物不同方法的不同遴选结果,运用灰色关联法,在系统内部对本文主要使用的六种遴选方法进行了定量的综合评分,得到了对各种方法的综合评分结果。结果排序有助于在选择方法时优先选择得分高的方法。各方法在具体指标下的得分结果,也可为决策者根据现行方法的薄弱之处,选择相应指标得分较高的“互补方法”与之搭配使用。
     根据基本药物目录整体,测算不同的目录方案结果对总药费负担、基本药物人口覆盖率等的影响效果,揭示隐藏在遴选方法背后的遴选精髓、测算出不同方法对应的不同目录方案的宏观卫生经济效果和社会效益。[结论]
     从微观遴选和宏观效益测算结果都表明,该文创新设计的遴选药物的背包模型方法,在参评六种方法的综合评价中得分最高,为首选方法,是最优解。世界卫生组织的专家委员会法紧随其后,层次分析法和我国现行专家库抽组的方法,综合效果也较好,是可替代解。药物经济学和循证评价的方法也是可行解,但是不建议单独使用,可以作为其他方法的配合。未来如使用背包模型法,建议借助计算机收集决策所需的客观信息,走信息化遴选的道路。此外,该文还针对我国目前基本药物没有专为儿童遴选的不足,补充分析了原因、提出了应借鉴世界卫生组织专家委员会法、加强遴选信息化建设,尽快进行儿童药物遴选等许多应用建议,也提出了许多有关遴选方法研究的学术拓展建议。
BACKGROUND
     In August 2009, after the impulse of the New Medical Reform, China launched her first National Drug Policy, aiming at effectively solving the problem of difficult and costly access to medicines, and toward balancing the service equality for the social vulnerable people, by initial establishment of the essential medicines system in the three years from 2009 to 2011. The selection of essential medicines is the jumping-off, key, and hard point for the subsequent process of production, supply, usage, reimbursement, clinical guide, and rational use of the essential medicines. However, the current research on the methodology of essential medicines selection is limited by the experts personal decision-making, and the objective, quantitative methods are in need, both domestically and internationally. The future jobs of updating the list of essential medicines per 3 years will also demand the improvement of the selection methodology.
     PURPOSE
     For better implement of the National Drug Policy and widening the system of essential medicines, this article is aiming at systematically concluding the several methods of essential medicines selection, by which it will supplement more quantitative, objective methods for the current subjective decision-making, and by the synthetic evaluation and systematical comparison of these different methods,it will provide more choices for the future update of the list of essential medicines and help the health managers to choose the proper method, according to the characteristics of every method, measure for measure.
     METHOD
     Based on the theories of public management, health governing management, evidence-based evaluation, social medicine, pharmacoeconomics, operations research, this dissertation systematically analyzed 6 methods of essential medicines selections, and then designed "structure-process-result" indicators of drugs policy, to quantitatively evaluate and compare the different methods by a scoring model.
     RESULT
     Take the medicines class of Benzylpenicillin for example, the experiment presented the sample of application of the above 6 methods, which resulted in 6 cases of lists of essential medicines with scorings by fuzzy synthetic evaluation.
     CONCLUSION
     The creative method of selection by Knapsack model ranked first in all the six methods and the method of World Health Organization Experts Committee took the second place in the synthetic evaluation. The method of Analytic Hierarchy Process and current method of China's Experts Review showed nice performances among the six methods. The Pharmacoeconomics method and the evidence-based evaluation got the lowest marks and were not that good to be used separately. Finally, this dissertation also gave some suggestions on the medical information construction for the future application of the quantitative methods, and proposed a new plan of computer-based information integration system for selection of essential medicines for Chinese children.
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