) Nghien C I F U - Ky thuat
Sif dung phan tich ABCA^EN danh gia hieu
r
qua can thiep cung m g thuoc tai Benh vien Nhan dan 115
Huynh Hien Trung', Doan Minh Phiic', Nguyin Thj Thiiy Ha' Nguyin Thanh Binh^ Tir Minh Koong^
' Benh vien Nhan dan 115 Thdnh pho HCM ' Truang dai hoc Duac He) Noi
D a t v a n d e
Phan tich ABC Id phan tich dya tren nguyen ly Pareto 'lly 1 s i it c6 y nghTa s i n g con t u s i nhiiu it CO y nghTa' '^ ^' va r i t hiju dung trong phan tich s u dung t h u i c ''', Phuang phap phan tich nay, phan chia cdc nhom t h u i c thdnh A, B, C vai ti le phdn tram ngan sdeh l i n lugt Id 80%, 15%, 5%. Phdn tich ABC thuang p h i i hap vd'i phan loai VEN (Vital: t i i c i n . Essential: thiit y i u , Non-Essential: kh6ng thiit y i u ) d i danh gia su dung thuic.
Trong cdc nghien cuu truo'C v i cung ung thuic tai Benh vien ND 115 (BVND115), chung t6i da d i cap tdi m6t s i b i t cap trong qua trinh su dung thuic tai BVND115, ching han nhu s i lugng va gia tri cac thuic khdng thiit y i u (cac vitamin va khoang chat, m6t s i thuic eo hieu qua diiu diiu tri khdng ro rang,..) chiim ty le cao trong tieu thu thuic cua benh vien ''', Chinh d i i u ndy da gop phin lam han e h i nguon kinh phi cho nhung thuic thiit y i u . De diiu chinh nhiJng b i t cap noi tren, mpt s i giai phap can thiep dugc tiin hanh de dieu chinh lai danh muc thuic cung ung tap trung vao thuic thiit y i u c i n thiit trong qua trinh diiu tri nhu: nang cao nang lye hoat ddng cua H6i ding thuic va d i i u tri, ra sodt lai danh muc thuic, loai bo nhi>ng thuic c6 hieu qua d i i u trj khdng r6 rang, gidm sat viec ke dan thuic d i han e h i viec su dung thuic kh6ng thiit y i u , trang bj phin m i m quan ly t h u i c . Nghien cuu ndy duac thyc hien nhIm danh gia hieu qua cua cdc giai phap can thiep tren.
P h u ' a n g p h a p n g h i e n CLPU Cac bien phap can thiep
Can c u vdo k i t qua phan tich tieu thu t h u i c nam 2006, thong qua Hoi d i n g t h u i c dieu tri vd
d i u t h i u t h u i c benh vien de rd sodt lai viec lua ehpn danh muc vd to chuc mua s I m va si>
dung t h u i c hang nam 2007, 2008:
(i) Chpn lya t h u i c : thuoc t i i c i n vd thuic thiit y i u duac uu tien lya chpn; han c h i hoac loai bo cac t h u i c khong t h i i t y i u ;
(ii) Mua thuic: (a) thuoc t i i c i n vd thuic thiit y i u d u g c kiem tra chat che; (b) M6 hinh VEN duge SLP dung dam bao du s i lugng thuic toi cdn va t h i i t y i u ; (c) chi nhlj'ng nhd cung cap CO uy tin duge lya chpn de cung c i p thuic (qua d i u thiu);
(iii) Phan p h i i : (a) gid thuoc: thuic thong dung, gia cao han c h i c i p phdt; (b) Kiem scat t h u i c t i n kho: dae biet ehu y d i n thuic t i i can vd t h u i c t h i i t y i u d i trdnh h i t thuic;
(iv) Phdn c6ng nhan vien: thu kho theo doi chat che t h u i c t i i can vd t h i i t y i u . T u 6/2008 trien khai dp dung p h i n m i m quan ly mdi quan ly t h u i c khoa kham, trong do c6 kho BHYT ngoai tru. Dir lieu ke dan cua bac sT duac truyin trye t i i p qua mang v i khoa dugc benh vien, nhan vien khoa d u g c kiem tra lai dIJ' lieu dan t h u i c truac khi c i p phat, p h i n m i m cung cap nhat s i lieu t i n kho tuc tho'i d i bde sT va nhan vien khoa d u g c n i m d u g c s i lieu thuoc thyc t i trong kho; d u lieu d y g e quan ly tu lue thuic nhap vao kho c h i n , x u i t kho, c i p phat.
quan ly ton kho, v. v...
Phan tich hieu qua can thiep
Thu thap cdc bdo cdo s u dung thuic tgi BVND 115 nam 2006 (truo'C can thiep), 2007, va 2008 (sau can thiep). Ap dung phyang ph^p phdn tich ABC/VEN '^ ^' de phan tich tinh hinh tieu thu thuoc truo'C vd sau can thiep.
12 TAP C H i DUQC HQC - 11/2009 (SO 403 NAM 49)
Nghien CLFU - Ky thuat
Cdc bud-c tinh todn ke tiep c6 the tbm luge nhu sau: gpi dan gid cua m6t thuoc Id gi (trong dd i chl m6t loai thuoc, i = 1, 2, 3, ..., N), qi Id so lugng thuoc su dyng, ci Id gid tri cua thuoc d6 (Q
= qi x g,). T i n g gid tri cua t i t ca cdc thuoc Id:
A'
^ = 1^1
N Id tong s i t h u i c s u dung. T u dd, p h i n tram gid trj Id prC/CxIOO. Dya vdo p h i n trdm gia tri (p,), chung tdi s l p x i p thu t y cdc thuic theo pi cao nhit d i n t h I p nhit, vd tu do ude tinh phan tram tich luy. Gpi p h i n tram tich luy Id k„ bude k i tiep, chung tdi phdn hang san p h i m theo tieu chuan c6 ten Id ABC: hang A g i m cac thuic vdi gid tri k| t u 0 d i n 80% (tCfC 80% ngan sdch thuic); hang B g i m cdc t h u i c vdi k, trong khoang 80 d i n 95%) (15% ngan sdch thuic); vd hang C g i m cdc t h u i c vdi k, cao han 95% (tuc 5% ngan sach thuic).
Can c u vdo y k i i n cua Hoi d i n g t h u i c d i i u trj benh vien, phdn loai cac t h u i c tren theo thu ty uu tien: T i i c i n thiit (V), thiit y i u (E) va kh6ng thiit y i u (N).
M6 hinh VEN duge so sdnh vdi phan tich ABC d i k i i m tra viec s u dung t h u i c hien tai so vdi nhOng thuic dugc uu tien:
V E N Thuoc toi cin, Thuic thiit Thuoc khong thiet A gia tri su dung yeu, gia tri su yeu, gia tri su
Idn (VA) dung Idn (EA) dung Idn (NA) Thuic tdi cin, Thuic thiet Thuic khdng thiet P gia tri su dung yiu, gia trj su yeu, gia tri su
trung binh (VB) dung trung binh (EB)
dung trung binh (NB)
Thuoc toi can, Thuic thiit Thuic khdng thiet _ gia tri su dyng yeu, gia tri su yeu, gia trj su
thap (VC) dung thap dung thip (NC) (EC)
K i t hgp phdn tich ABC, VEN dugc cac gid trj VA, VB, VC, EA, EB, EC, NA, NB, NC so sanh tung cap gia trj ndy trudc vd sau can thiep vdi nhau.
Muc ti§u chinh cua nghien cuu Id ddnh gia hieu qua cua can thiep trong thai gian 2006- 2008. Cau hoi cu the Id cdc phan trdm gia trj p, thay d i i ra sao trong tho'i gian trudc vd sau can thiep. Bdi vi s i lieu dugc thu thap qua 3 ndm, n6n md hinh h i i qui t u y i n tinh (linear regression model) dugc ung dung d i ude tinh ty le thay doi trong 3 ndm. Theo md hinh ndy.
gpi ty 16 gid trj s u dung m6t nh6m thuoc cua ndm f Id p,, trcng dd, t c6 gid trj 2006, 2007 vd 2008. LTdc tinh ty s u i t thay dpi cua p, qua 3 ndm vdi mo hinh sau ddy: p,= a + bt+ e,. Trong md hinh ndy, a Id diem khai d i u (ndm 2006), b Id ude s i cua ty suit, vd e, Id "phdn du"
(residual) cua md hinh. Theo gia djnh, e(tuan theo ludt phan p h i i chuan, vdi trung binh 0 vd mpt phuang sai b i t b i i n , b chinh Id ude so khach quan v i ty s u i t thay doi trong 3 ndm.
Nhung vi p, dugc tinh todn t u gid trj b l n g t i i n , cho nen trong phdn tich, chung tdi cung can phai d i i u chinh cho gid trj t i i n Ct b l n g phuang phap ude tinh Weighted Linear Regression.
K i t qua va ban luan
v i s6 chung loai thudc
Bang 1: So sinh ty le (theo chung loai thudc) nhom A, B, C truac va sau can thiep
Nhdm Nam 2006 Nam 2007 Nam 2008 A 110(14,7%) 87(13,4%) 91 (13,0%) B 166(22,2%) 123(19,0%) 142(20,3%) C 471(63,1%) 439(67,6%) 467(66,7%) V i chung loai thuic, trudc can thiep (ndm 2006) s i ehung loai t h u i c s u dung trong benh vien Id 747 loai, sau can thiep nam 2007 s i chung loai thuic giam cdn 649 loai (giam 13,1%), vd d i n nam 2008 cdn 700 loai (giam 6,7%) so vdi ndm 2006. So vdi nam 2006, s i thuic nhdm A giam 1,3%) vdo nam 2007, vd giam 1,7% vao ndm 2008.
v i ty le cac nhom t h u i c
Bang 2: So sinh ty le (theo gii tri s(> dung) nhdm N, VE nam 2006, 2007, 2008
_..- 2006 2007 2008 Ty s u i t (sai sd ^ . ; „ Bien ' . I , T n s o P
(%) (%) (%) chuan)
N 17,09 15,40 14,34 -1,37% (0,18) 0,008 VE 82,91 84,60 85,66 1,36% (0,18) 0,008 Nam 2006 (trudc can thiep) t h u i c N (khdng thiit yiu) c h i i m 17,1% tong so, nhung sau khi can thiep, ndm 2007 ty le nhdm thuic N giam xuing 15,4%, va d i n ndm 2008 thi cdn 14,3%o.
Tinh trung binh ty le t h u i c nhdm /Vgiam - 1 , 4 % mdi nam vd ed y nghTa thong ke vdi tri s i P = 0,008 (bang 2). Nguge lai, nhdm thuic thiit y i u V, N (bao g i m VA, VB, VC, EA, EB, EC) tdng tu - 8 3 % ndm 2006 len - 8 5 % nam 2007 vd - 8 6 % nam 2009. Tinh trung binh ty le nhdm
TAP CHi DUQC HQC - 11/2009 (SO 403 NAM 49) 13
Nghien CLFU - Ky thuat
thuoc V, N tdng 1, A% m i i ndm vd ty le tdng ndy cung cd y nghTa thong ke (P=0,008). Ty 10 Chung loai thuoc N giam; ty le thuoc toi c i n (V), thiit y i u (E) tang len d u g c ly giai Id do cdc y i u t i can thiep trong qud trinh lya chpn thuoc, Hpi d i n g thuic vd d i i u trj benh vien da loai bdt cdc loai thuoc khdna thiit y i u nhu Alphachymotnpsin, mpt s i thuic non-steroid, t h u i c hieu qua dieu trj khdng r6 rdng; tang cudng cac t h u i c thu6c nhdm thuic t i i c i n , t h i i t y i u .
Bang 3: Phan tich ABC trong nhom N nam 2006. 2007, 2008 (ty le theo gia tri)
Biin NA NB NC
2006 (%) 9,56 5,50 2,03
2007 (%) 8,05 5,89 1,46
2008 (%) 7,34 5,23 1,76
Ty s u i t (sai sd chuan)
-3,76(0,16) -3,34 (0,67) -2,80 (0,35)
Trj sd P 0,001 0,018 0,007 Trong nhdm N qua cdc ndm (theo bang 3), ty le cdc nhdm thuic A, B, C giam trung binh l i n lugt Id -3,8%, 3,3%), vd 2,8%>; cac iy le giam ndy d i u cd y nghTa t h i n g ke. T h u i c kh6ng thiit y i u (N) giam the hien sy hgp ly trong SLP dung thudc, vi ddy Id nhdm thuic khdng t h i i t y i u nhung su dung nhieu ngdn sdch
v i ty le cac nhom t h u i c bao h i i m y t i (BHYT) ngoai tru
Ty le nhdm thuic N d khu vyc nay giam trung binh - 2,7% vdi P = 0,041 (ed y nghTa thing ke); ty le ndy tuang ung ty le tdng nhdm V, N Id 2,7% va cung cd y nghTa t h i n g ke (P = 0,038) (theo bang 4).
Bang 4: So sanh ty le (theo gia tri su dung) nhdm N, VE nam 2006, 2007, 2008 a khu vuc BHYT ngoai tru
„..- 2006
^'^" (%) N 42,78 VE 57,22
2007 (%) 41,49 58,51
2008 (%) 37,43 62,57
Ty suat (sai sd chuan)
-2,68 (0, 82) 2,73 (0, 80)
Trj sd P 0,041 0,038 Xet chi tiet cdc nhdm N d khu vyc BHYT ngoai tru, ty le nhdm NA giam d i n theo tung ndm, giam trung binh - 2,5% vd s y ty s u i t giam ndy ed y nghTa t h i n g ke (P < 0,05) (theo bang 5). Tyang tu, ty s u i t cdc nhdm NB giam - 0, 2% vd ed y nghTa t h i n g ke (P < 0,05). Cdn nhdm NC, ty s u i t giam khdng ed y nghTa thong ke (P > 0,05). Ty s u i t giam nhdm NA vd NB cd y nghTa thing ke d khu vyc BHYT ngoai tru, d i n g thd; cung ed y nghTa cho viec t i i t kiem ngan sdch thuic vi nhdm A, B Id nhdm s u dung nhiiu ngdn sdch.
Bang 5: Phin tich ABC trong nhdm N nSm 2006. 2007, 2008 (ty Id theo gii tri) & khu vi/c BHYT ngoai tru
B i i n NA NB NC
2006 (%) 33,81
6,75 2,22
2007 (%) 32,58
6,55 2,36
2008 (%) 28,86
6,46 2,11
Ty suat (sai so ^ . .- _ ' . 1 . Tn so P
chuan)
-2,48(0,71) <0,05 -0,15(0,03) <0,05 -0,06(0,11) >0,05 Dieu ndy cd the giai thich Id do cdc tac dpng can thiep lien tuc cua Hpi dong thuoc d i i u tn:
phdn tich dan thuoc, kiem sodt danh muc thuic cung ung cho BHYT ngoai tru... Vdo thang 6/2008, benh vien trang bi p h i n m i m mdi:
quan ly ke dan qua mang vd quan ly ton kho qua mang, nhlj'ng giai phdp k i t hgp ndy cd t h i Idm cho ty le nhdm t h u i c nhdm NA giam nhiiu han trong nam 2008 so vdi ndm 2007.
v i ty le cac nhom thudc Bao hiim y t§
npi tru
Bang 6: So sinh ty le (theo gii tri su dung) nhdm N, VE nam 2006, 2007, 2008 khu vuc BHYT noi tru
„ . . 2006
^'^" (%) N 10,15 VE 89,85
2007 (%) 8,06 91,94
2008 (%) 8,96 91,04
Ty suat (sal sd chuan)
-0,60 (0,9) 0,60 (0,9)
Tn sd P
>0,05
>0,05 Ty le nhdm thuoc khdng t h i i t y i u N (bao g i m NA, NB vd NC) giam trung binh 0,6% va khdng ed y nghTa thong ke (P> 0,05). Ty le nhdm t h u i c VE (bao g i m VA, VB, VC, EA, EB, EC) tang t u a n g Cpng cung chinh bdng ty le cac thuoc nhdm N giam vd cung khdng cd y nghTa t h i n g ke (P> 0,05).
Phdn tich nhdm N, k i t qua the hien theo bang 7:
Bang 7: Phan tich ABC trong nhdm N nam 2006, 2007, 2008 (ty le theo gid tri) d khu vyc BHYT ndi tru
B i i n NA NB NC
2006 (%) 4,30 4,20 1,66
2007 (%) 2,56 4,11 1,39
2008 (%) 3,74 3,51 1,71
Ty suat (sai so ^ . .- „ ' . I . TnsoP
chuan)
-0,30 (0,8) > 0,05 -0,35(0,15) <0,05
0,03(0,17) >0,05 Nhdm NA vai ty s u i t giam trung binh Id 0,3% vd khdng cd y nghTa thong ke (P> 0,05), nhung ty s u i t NB giam trung binh 0,35% vd c6 y nghTa t h i n g ke (P< 0,05). Rieng ty s u i t nhom
14 TAP C H i DUQC HQC - 11/2009 (SO 403 NAM 49)
Nghien ciPu - Ky thuat
NO lai tdng trung binh 0,03%) (P> 0,05). Tuy nhifen, do nhdm NC cd gid trj thap ndn ty suat ndy tdng Id rat nho so vdi ty s u i t giam cua NA vd NC. Vi&c cdc nhdm thuoc d khu vyc n6i tru giam du khdng cd y nghTa t h i n g ke (tru nhdm NB), nhung ed y nghTa cho viec tiit kiem ngan sdch vi khu vyc ndy s u dung mpt lygng Idn ngdn sdch thuic.
B a n l u a n ^ ,
Ty le cdc nhdm thuoc N nhin chung giam sau can thiep (ndm 2007, 2008 so vdi 2006) vdi ty suit trung binh ~ 1,4%) (tuang ung ty s u i t tang cua nhdm V, N). Ty s u i t nhdm N d khu vyc ngoai tru giam trung binh - 2,7%, trong khi dd ty suit giam nhdm nay d khu vyc npi tru la 0,6%.
Ty suit giam nhiiu vd on djnh d khu vyc ngoai tru Id do ngodi cdc y i u t i can thiep dp dung nhu khu vyc npi tru; khu vyc ngoai tru cdn cd them cdc y i u t i khde Id p h i n m i m mdi, kiem sodt t i n kho, phdn tich dan thuic... Ty s u i t nhdm NA giam chung trung binh Id - 3,8%o; ty s u i t ndy clJng giam nhiiu d khu vyc ngoai tru - 2,5% so vdi - 0,3% d ndi tru. Ddy Id nhdm quan trpng cdn tap trung quan ly t i t vi tieu t i n nhiiu ngdn sdch, viec c i t giam nhdm ndy de ddnh ngdn sdch mua nhdm V, N Id c i n thiit. Trong nghien cyu, mdc du mpt s i ty s u i t thay d i i kh6ng e6 y nghTa thing ke, nhyng sy giam ndy c6 y nghTa v i ngdn sdch thuic. Phuang phdp t i i p can cua nghien cuu n i u dp dung cho nhieu benh vien trong ca nude thi se ed Igi Idn cho ngdn sdch nhit Id trong d i i u kien cdc nguin lye ngdy edng kho khdn han. Tuy nhien, sau can thiep ty suit nhdm ndy v i n cdn d muc cao 14,34%o ndm 2008, nen Hdi d i n g thuic vd d i i u trj c i n t i i p tuc duy tri cdc bien phdp can thiep d i giu on djnh cdc ty suit da giam ndy vd cd the t i i p tuc Idm giam han niia. Sau nghien cuu ndy, c i n cd cdc nghien cuu ddnh gid s u dung thuic v i nhdm thuic N (khdng thiit y i u ) ndy.
Ket luan
Vdi cdc giai phdp can thiep lien quan d i n lua chpn thuic thdng qua Hpi d i n g thuic d i i u trj, vi6c cung ung thuic tai BVND 115 dd dugc cai thien mpt cdeh ddng k i ; trong hodn canh han hep v i kinh phi, t i i n mua cdc loai thuic khdng thiit y i u dung trong benh vien giam xuing vd kinh phi duge h i trg t i i da cho thuic thiit y i u dd phuc vu thiit thyc cho c6ng tdc d i i u tri.
Sumarry
This study was undertaken to assess the efficacy of management intervention on the adequacy of drug supply at Nhin din Hospital 115 (People's Hospital 115, HCM city). A systematic audit was performed with respect to drug usage in the hospital during the period of 2006 (intervention initiation) to 2008 (after intervention). Drugs were divided into 3 groups:
vital drugs (V), essential drugs (E) and non- essential drugs (N). The intervention involved regular stock inventory, strict control on the supply of the vital and essential drugs and computerization of the drug management. The intervention was perfomed from June 2008 afterwards. The percentage of each drug group (V, E and N) was determined for each year, and its percentage variation between 2006 and 2008 was estimated by the weighted linear regression model.
Prior to the intervention (2006) non-essential drugs accounted for 17.1% (of total dnjg value) and later, after intervention, reduced to 15.4% for 2007 and 14.3% for 2008. On average, the rate of reduction was ca. 1.4% per annum (pa) (P=0.008).
On the other hand, the percentage of vital and essential drugs increased by 1.4% pa (P=0.008).
Of non-essential drugs, section A reduced by 3.76% pa (P=0.001). section B were also decreased by 3.34%, pa. (P=0.018). the percentage of section C was reduced by 2.8%> pa (P=0.007). For the out-patient department (OPD).
the percentage reduction of the non-essential dmgs was 2.7%, pa (P=0.041) against 06%, (P>0.05) for the in-patient departments (IPDs).
The management intervention proved quite effective in reducing the consumption of the non-essential drugs, and at the same time, increasing that of the essential and vital ones.
Tai lieu tham khao
1. Huynh Hien Tmng, Doan Minh Phuc, Nguyen Thanh Binh, Tu Minh Koong, Danh gia ting quat tinh hinh su dung ngan sach thuoc tai Benh vien Nhan dan 115 nam 2006, Tap chi Duac hgc. s i 381, (2008)
2. Kathleen Hollow/ay, Ten^ Green. Cam nang hudng din thuc hanh, Hpi ding thuoc va dieu tri, (2003)
3. Jonathan D. Quick, James R. Rankin, Richard 0. Laing, Ronald W. O'Connor, Hans V. Hoserzeil, M.
N. G. Dukes, Andrew Garnett, Managing Drug Supply (1997), Kumarian Press.
TAP C H i DUQC HQC - 11/2009 (SO 403 NAM 49) 15
