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医保DRG付费改革背景下老年肿瘤患者潜在不适当用药的变化趋势分析
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| 篇名： | 医保DRG付费改革背景下老年肿瘤患者潜在不适当用药的变化趋势分析 |
| TITLE： | Analysis of trends in potentially inappropriate medication among elderly cancer patients in the context of DRG-based medical insurance payment reform |
| 摘要： | 目的 分析医保疾病诊断相关分组（DRG）付费改革背景下老年肿瘤患者潜在不适当用药（PIM）的变化趋势。方法提取某三级甲等医院2018年1月－2025年3月老年肿瘤住院患者的相关数据，使用中国老年人PIM判断标准2024版及美国Beers标准2023版对其医嘱用药进行PIM筛查并进行一致性评价。建立中断时间序列（ITS）模型，分别以2018年1月－2020年12月为实施前组、2021年1月－2025年3月为实施后组，分析实施医保DRG付费改革对老年肿瘤住院患者人均住院费、人均住院日、人均用药品规数、总PIM发生率及目标药物PIM发生率的影响；为消除基线资料（年龄、性别）影响，进一步采用倾向评分匹配，再借助ITS模型分析实施医保DRG付费改革对老年肿瘤住院患者总PIM发生率的影响。结果共纳入16910例老年肿瘤住院患者（实施前组6552例、实施后组10358例）；发生PIM的有9138例，发生率为54.04%；PIM涉及198种药物，其中平均PIM发生率较高或趋势变化明显的目标药物包括双氯芬酸钠肠溶胶囊、盐酸羟考酮缓释片等6种；2名药师判定结果一致性评价的Kappa值为0.931（P＜0.001）。该院实施DRG后，患者人均住院费每月下降趋势103.501元（P＜0.001）；人均住院日稍有延长趋势（每月延长0.052d，P＝0.017），但实际斜率（－0.036）小于0；人均用药品规数无显著变化（P＝0.193）；医保DRG付费改革可对双氯芬酸钠肠溶胶囊、多索茶碱注射液、西咪替丁注射液使用者的PIM发生率产生具有统计学意义的瞬时冲击效应（P分别为0.041、0.001、0.036），对盐酸羟考酮缓释片使用者的PIM发生率产生具有统计学意义的长期趋势效应（P＝0.008），对螺内酯片、氨茶碱注射液使用者的PIM发生率产生具有统计学意义的瞬时冲击效应和长期趋势效应（P分别为0.035、0.031和0.009、0.031）；无论是否进行PSM，患者的总PIM发生率均呈轻度上升趋势[每月上升0.228%，P＝0.001（未经PSM时）或每月上升0.239%，P＜0.001（经PSM后）]。结论医保DRG付费改革实施后，老年肿瘤住院患者的人均住院费显著下降，人均住院日实际下降趋势变缓，总PIM发生率呈轻度上升趋势，且不同品规药物的PIM发生率变化趋势存在异质性。 |
| ABSTRACT： | OBJECTIVE To analyze the trends of potentially inappropriate medication （PIM） among elderly cancer patients in the context of the diagnosis-related groups（DRG）-based medical insurance payment reform.METHODS Relevant data were extracted for elderly inpatients with cancer at a Grade-A Level-Ⅲ hospital from January 2018 to March 2025. Prescribed medications were screened for PIM using the 2024 Chinese Criteria for Identifying PIM in the Elderly and the US 2023 Beers Criteria， and consistency was evaluated. An interrupted time-series （ITS） model was established， with the period from January 2018 to December 2020 designated as the pre-implementation group， and January 2021 to March 2025 as the post-implementation group. The study analyzed the impact of the medical insurance DRG payment reform on per capita hospitalization costs， per capita length of stay， average number of medication specifications per patient， overall PIM incidence， and PIM incidences for target medications among elderly cancer inpatients. To eliminate the influence of baseline characteristics （age， sex）， propensity score matching（PSM） was further applied， followed by an ITS model analysis to assess the impact of the DRG payment reform on the overall PIM incidence among elderly cancer inpatients.RESULTS A total of 16 910 elderly cancer inpatients were included （6 552 in the pre-implementation group， and 10 358 in the post-implementation group）； PIMs occurred in 9 138 patients， with an incidence of 54.04%. PIMs involved 198 types of medications， among which six target medications （including Diclofenac sodium enteric capsules and Oxycodone hydrochloride sustained-release tablets）， exhibited a higher average PIM incidence or a significant trend change； the Kappa value for the consistency evaluation of the assessments by two pharmacists was 0.931 （ P ＜0.001） . After the implementation of DRG， the per capita hospitalization costs showed a downward trend of 103.501 yuan per month （ P ＜0.001）； the per capita length of stay showed a slight upward trend （increasing by 0.052 days per month， P ＝0.017）， but the actual slope （－0.036） was less than 0； there was no significant change in the average number of medication specifications per patient （ P ＝0.193）. The DRG payment reform under medical insurance can produce statistically significant instantaneous impact effects on the PIM incidences among users of Diclofenac sodium enteric capsules， Doxofylline injection， and Cimetidine injection （ P values of 0.041， 0.001， and 0.036， respectively）， a statistically significant long-term trend effect on the PIM incidences among users of Oxycodone hydrochloride sustained-release tablets （ P ＝0.008）， and statistically significant instantaneous shock and long-term trend effects on the PIM incidences among users of Spironolactone tablets （ P values of 0.035 and 0.031） and Aminophylline injection （ P values of 0.009 and 0.031）. Regardless of whether PSM was applied， the overall PIM incidence among patients showed a slight upward trend [an increase of 0.228% per month， P ＝0.001 （without PSM）， or an increase of 0.239% per month， P ＜0.001 （after PSM）].CONCLUSIONS Following the implementation of the DRG payment reform for medical insurance， the per capita hospitalization cost for elderly inpatients with cancer decreases significantly， while the decline in the per capita length of stay slows. The overall PIM incidence shows a slight upward trend， and the trends in PIM incidence vary across different drug formulations. |
| 期刊： | 2026年第37卷第18期 |
| 作者： | 刘永辉；赵敏；张晓琳；黄明媚；张宏亮 |
| AUTHORS： | LIU Yonghui，ZHAO Min，ZHANG Xiaolin，HUANG Mingmei，ZHANG Hongliang |
| 关键字： | 老年人;肿瘤患者;潜在不适当用药;医保DRG付费改革;中断时间序列;共病 |
| KEYWORDS： | Elderly;cancer patients;potentially inappropriate medication;DRG-based medical insurance payment reform;interrupted time-series;comorbidity |
| 阅读数： | 1 次 |
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