Tóm tắt Luận án 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

d therefore it is necessary to further study these parameters at the central level. 6 + 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. CHAPTER 2. SUBJECTS AND RESEARCH METHODS 2.1. Subjects * 11 facilities that meet the research conditions. 7 * 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: 8 Table 2.2. The number of samples to be divided according to 11 healthcare facilities No. Healthcare Facilities No. of prescriptions No. of patients 1 Binh Thuy 136 136 2 Co Do 249 249 3 O Mon 681 681 4 Thot Not 630 630 5 Cai Rang 163 163 6 Phong Dien 303 303 7 Thoi Lai 377 377 8 Vinh Thanh 304 304 9 Can Tho Central General 218 218 10 CTUMP 100 100 11 Can Tho City General 885 885 Total 4,046 4,046 After intervention, samples with disease patterns, age group, gender, education level are similar to those of before intervention. The number of samples that needs to be collected at 3 healthcare facilities after intervention is equal to that of before intervention. 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 9 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. * Evaluation of SCT: Review the status of prescription: the compliance with regulations on drug prescriptions, prescription indexes, rational use of drugs have not been achieved at 3 healthcare facilities. 10 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 11 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. 12 * The ratio of applications having injections: the general percentage is 0.9%. * The ratio of applications vitamins: the rate is 24.7%. * The proportion of applications with corticosteroids: the general rate for 11 health facilities is 12.1%. Phong Dien district healthcare center accounted for the highest rate of 22.8% and the lowest rate belonged to Can Tho University of Medicine and Pharmacy Hospital with 4.0%. Prednisolone and Methyl prednisolone are 2 corticosteroids usually used by doctors. * The percentage of prescription drugs included in Essential drug list and Main drug list: the average percentage of Essential drug used is 41.98% and Main drug is 63.07%. 3.1.2. Evaluate the effectiveness of some interventions in prescribing for outpatient at some public healthcare facilities in Can Tho city in the period of 2017-2018 3.1.2.1. Compliance with regulations in prescribing for outpatient After the intervention, the percentage of compliance with the regulations on correct addressing in O Mon district general hospital was increased but it was not significant. This index in Can Tho university of Medicine and Pharmacy hospital and Phong Dien healthcare center had a significant increase with p < 0.05 when Can Tho university of Medicine and Pharmacy hospital increased from 85.0% to 100.0% and Phong Dien district healthcare center increased from 90.8% to 100.0%. Requirements on recording drug quantity less than 10 compliance rate after intervention at Can Tho university of Medicine and Pharmacy hospital has changed but not significant with p > 0.05. Particularly, Phong Dien district healthcare center had a statistically significant increase with p < 0.05 in the regulation on drug name, concentration/content, quantity, dose, route, time of use of each drug from 62.7% to 93.2%. 13 3.1.2.2. Prescription indicators * Average number of drugs in a prescription after intervention: Table 3.24. The average number of drugs in a prescription after intervention No. Health facility No. of pres. Quartile p Q25 Q50 Q75 1 CTUMP Before 100 3 4 5 > 0.05 After 100 3 4 5 2 O Mon Before 681 4 4 4 < 0.05 After 681 4 4 5 3 Phong Dien Before 303 5 6 6 > 0.05 After 303 5 6 6 The average of total number of drugs prescribed by O Mon district general hospital increased significantly after intervention from 4.00 to 5.00 drugs in a single prescription with p < 0.05 and Q75, however this increase is not clinically significant. 3.2. Results of assessing the situation of patient care and the effectiveness of some interventions in taking care of patients with outpatient health insurance at some public health facilities in Can Tho city in 2016 -2018 3.2.1. Results of the assessing the situation of taking care of patients with outpatient medical insurance in some public health facilities in Can Tho city in the period of 2016-2017 3.2.1.1. Patient care indicators * Average medical examination time: the lowest and highest medical examination time in each hospital was 0.2 minutes and 33.10 minutes, respectively. The overall average for this study is 2.64 minutes. 14 * Average dispensing time: this research result is high, however, in our opinion, it is mainly the waiting time at the health insurance dispensing office due to the large number of patients rather than the direct communication time between allocation staff and patients. * The percentage of drugs actually distributed: the average percentage of actually distributed at 11/11 health facilities is almost absolute, reaching 99.96%. * The percentage of fully labeled applications: the percentage of labeled drugs is as low as 47%. * The patients' understanding of using dose: knowledge about the duration of treatment is 77.1%, how to use the medicine is 76.4%, the dosage of each type of medicine is 75.3%, the time to use medicine is 76.7%. 3.2.1.2. Patient satisfaction in healthcare service Regarding accessibility, the average of level 4 and level 5 at 11 health facilities was quite high, at 71.58%. Information transparency and procedures to achieve satisfaction level of 4 or more with the rate of over 80% in 3 health facilities: Phong Dien district healthcare center, Cai Rang district healthcare center, Thoi Lai district healthcare center. The average percentage of 11 medical facilities was 71.77%. The attitude and professional capacity of health workers at the survey facilities is assessed to be quite high. 3.2.2. Evaluate the effectiveness of some interventions in outpatient care in some public health facilities in Can Tho city in the period of 2017-2018 3.2.2.1. Patient care indicators * Average time of examination: after intervention, time of examination in all 3 hospitals increased significantly with p < 0.05. Can Tho university of Medicine and Pharmacy increased from 2.50 minutes to 5.09 minutes, O Mon district general hospital increased 15 from 2.25 minutes to 4.62 minutes and Phong Dien district healthcare center increased from 1.88 minutes to 3.93 minutes. It can be said that the interventions are somehow effective. * Average delivery time: Table 3.37. Average drug delivery time after intervention No. Health facility No. of pres. Quartile p Q25 Q50 Q75 1 CTUMP Before 100 5.24 5.8 6.33 < 0.05 After 100 5.77 6.29 6.53 2 O Mon Before 681 4.75 6.58 7.83 < 0.05 After 681 6.34 7.65 9.68 3 Phong Dien Before 303 2.43 3.1 5.5 < 0.05 After 303 5.45 6.07 6.42 Similar to the time of examination, the time of drug dispensing also increased to statistical significance with p < 0.05. This is also a good sign to prove the effectiveness of interventions. * The percentage of prescription which drugs fully labeled after intervention: significant increase in all 3 hospitals with p < 0.05. This improvement is significant with Can Tho university of Medicine and Pharmacy hospital increasing from 30% to 51%, O Mon district general hospital from 16.7% to 36.1% and Phong Dien district healthcare center from 35% to 55.1 %. * Patient's understanding of their treatment: the patient's knowledge about 4 surveyed variables increased, but mostly not statistically significant. 3.2.2.2. Patient satisfaction with health care service Regarding the provision of medical services, there was a decrease in the percentage of high level of satisfaction at O Mon district general hospital, a slight increase at the two other hospitals, but the increase or decrease mostly did not have statistical 16 significance. The majority of patients' satisfaction with accessibility increased after intervention, Phong Dien district healthcare center increased the highest by 12.28%, Can Tho university of Medicine and Pharmacy hospital increased by 8% and O Mon district general hospital increased by 3.08%. The transparency of information and procedures with the highest satisfaction rate among patients going to outpatient health insurance after intervention and highest at Can Tho university of Medicine and Pharmacy hospital with all the variables are statistically significant. In terms of facilities, this hospital also had a statistically satisfaction in high level. In terms of attitude, the professional competence of employees with high satisfaction rate has decreased but not much, most of them are not statistically significant (p > 0.05). CHAPTER 4. DISCUSSION 4.1. Situation of prescribing and effectiveness of some interventions in prescribing health insurance drugs for outpatients at public health facilities in Can Tho city during the period of 2016-2018 4.1.1. Situation of prescribing health insurance drugs for outpatients at public health facilities in Can Tho city during the period 2016-2017 4.1.1.1. Compliance with regulations on outpatient prescription * Compliance with regulations on administrative procedures: Insufficient addressing was due to a variety of reasons. For example, with regard to disregarded information, doctors who have to deal with a great number of patients might think that such administrative regulations do not affect the examination results and thereby ignoring information about patients. * Compliance with regulations on content of prescriptions: 17 The analysis of results showed that the processes of disseminating and guiding the regulations on prescription for doctors have not been synchronized. In addition, the dispensing of drugs in the Department of Pharmacy only focused on considering the appropriateness of prescribed drugs rather than focus on other provisions of the prescription regulations. Therefore, doctors were still subjective and ignored regulations on content of prescriptions. 4.1.1.2. Prescription indicators * The average number of drugs in a prescription: Prescriptions had a high number of drugs because most patients suffered from many diseases. The most common ICD codes were typical conditions of the elderly namely I10-idiopathic hypertension (15.7%), K29-gastritis, duodenitis (9.35%), E11-Non Insulin Dependent Diabetes Mellitus (7.29%). * The rate of drugs prescribed under generic or international generic names: The application of information technology to prescriptions may overcome the problem of prescribing with non-generic name. Particularly, in Cai Rang district health center, the percentage of drugs prescribed with generic name was the lowest, at 71.66%. The reason was that the Faculty of Pharmacy did not closely follow the regulations when sending the list of drugs to the IT department. As a result, some single substance drugs were put on the software without their active substance name, which led to the situation of doctors prescribing brand names. Therefore, such rate did not meet the WHO's recommendations. * The rate of prescription with antibiotics: The reason for the differences among health facilities was that the disease patterns of prescription drugs in surveyed samples were not the same. In-depth analysis of antibiotic combinations, cases of 18 using 2 or 3 antibiotics mainly combined 2 drugs with different forms of use, mainly oral and ophthalmic eye drops antibiotic or topical antibiotic or according to the treatment regimen of H. pylori stomach ulcers. * The rate of prescription with injecting medicine: Results showed that the healthcare facilities did not abuse this kind of drug. The reason why there were 5 medical facilities which did not use injecting drugs in the list of outpatient health insurance drugs was that they were graded III in the classification of healthcare facilities. Therefore, the permissible health insurance ceilings were lower. Injecting drugs were high-cost drugs; therefore, in 5 health facilities, they were only in the list of inpatient medical insurance drugs. * The rate of prescription with vitamins: According to WHO, this indicator does not have ideal level which was researched by the Ministry of Health of Vietnam and a number of countries to monitor the use of vitamins in prescription, as well as to avoid overuse of vitamins. * The rate of prescription with corticosteroids: The corticosteroids in the survey were mainly used for the treatment of inflammation, asthma or topical application in topical products. None of the corticosteroids were abused or misused based on diagnoses. * The rate of prescribed drugs in essential medicine list and main medicine list: The percentage of prescription drugs in surveyed facilities’ essential medicine list/main medicine list was low. Doctors were only allowed to prescribe drugs in the presented lists; therefore, it was seen that the cause of low rate of prescribed drugs in essential medicine list and main medicine list was not from doctors. 19 4.1.2. Effectiveness of some interventions in prescribing medicines for outpatients at public health facilities in Can Tho city during the period of 2017-2018 4.1.2.1. Compliance with regulations on prescribing for outpatients Interventions such as promoting the implementation of regulations, educating and enhancing knowledge by directly propagandizing regulations on prescriptions, distributing materials and regularly reminding during professional meetings has effectively impacted on the awareness and strict adherence to the regulations regarding prescribing. 4.1.2.2. Prescription indicators * The average number of drugs in a prescription: This result also highlighted the need to raise awareness of physicians about prescription. Medical facilities should have measures for prescribers to be able to calculate the cost of medicine right after prescribing so that they can adjust the price of prescriptions in accordance with the affordability of the patients as well as the health insurance provisions. 4.2. Situation of patient health care and effectiveness of some interventions in healthcare of outpatients with health insurance at some public health facilities in Can Tho city during the period of 2016-2018 4.2.1. Situation of patient health care at some public health facilities in Can Tho city during the period of 2016-2018 4.2.1.1. Patient health care indicators: * Average time for medical examination: This indicator was not achieved because the state healthcare facilities in Vietnam in general and Can Tho in particular, especially district healthcare facilities, with relatively few facilities and the lack of human resources, which led to overcrowding. In addition, doctors 20 who were not only in charge of medical examination and treatment, but also had to carry out other administrative tasks, thus having a great work pressure which partly limited the effectiveness of medical examination and treatment. * Average drug dispense time: In 4,046 surveyed cases, drug dispensers mainly counselled on special drugs or when being requested from patients. The counsel content was dosage, usage, frequency and duration of administration. This was partly due to the fact that the medical staffs thought that patients had been counselled by physicians and patient prescriptions had quite adequate instructions for using the drug, thus not paying too much attention to such issue. * The rate of drugs actually distributed: Drug management software provided by Hau Giang Pharmaceutical Joint-Stock Company was used by 11 health facilities surveyed. Accordingly, only drugs in the warehouse were included in the drug list. Doctors prescribed based on such software and Pharmaceutical department did not have to notify the status of existing drugs to the departments. * The rate of sufficiently labelled prescriptions: This result was low due to the pressure and workload during hospital busiest hours when continuous drug dispenses interfered with the preparation of adequate information on drug use instructions in the patient medicine bags. Moreover, the majority of dispensers believed that most of information was already on patient prescriptions so labelling was not necessary and patients only have to follow drug use on the prescription. Instead of writing in detail, verbal instructions were given to patients. * Patient understanding of