Discussion of Methodology
The majority of analytical observational[21] studies assessing the association between an exposure and an outcome were cross-sectional studies, cohort or case-control studies. The advantages of cross-sectional studies [22] were easy and quick to conduct and less expensive compared with cohort or case-control studies. The information on attitudes, knowledge and regulation practice, which was available only from cross-sectional studies, was useful for planning health interventions. Point-prevalence surveys [23] were useful when time and resources didn’t allow for continuous surveillance. Repeated point-prevalence surveys within the same institution could be used to monitor trends and effectiveness.
Sampling method was very important for the comparability of date. The sample size was the compromise between statistically goals and feasible ways. WHO/INRUD suggested that one year or longer and large cases were demanded to minimize bias due to seasonal variations or interruptions in the drug supply cycle[24]. In 2006 we sampled prescriptions of September 1, then September 2… until September 10, then the next year, until 2009. In 2006 we totally sampled 1180 from 36581 prescriptions; the sampling percent was 3.23%. In 2012 we sampled 1171 from 38246 adult ordinary prescriptions; the sampling percent was 3.06%.
According to the related regulations, every prescription was assumed to be from one encounter. Compared the WHO and Chinese indicators of Prescription Management Regulation, the difference was that "every encounter" was emphasized in WHO indicators, while "every prescription" was emphasized in Chinese regulations.
The ‘Guidelines for Clinical Application of Antibacterial Drugs’ in 2015 required that percentage of inpatient prescriptions with an antibiotic prescribed should be less than 20%, percentage of emergency prescriptions with an antibiotic prescribed should be less than 40%, the defined daily dose(DDD) should be less than 40. The pediatric patients thought that injections were more convenient, effective, poorer compliant than oral drugs. They required clinicians to use injection and antibiotics. Because of serious diseases and anxious conditions of emergence patients, more injection and antibiotics could be used by the emergency and pediatric physicians. In order to minimize bias, only the adult ordinary prescriptions were included in our calculation. The departments of pediatrics, emergency and TCM were excluded.
Discussion of Rational Drug Use
A questionnaire was designed to evaluate the knowledge levels of physicians[25], total of 334 physicians in 60 county hospitals filled out the questionnaires and 385,529 prescriptions were collected. But there was still a popular belief in China that injections and antibiotics were more convenient and effective[26], which was very common that patients demanded injections and antibiotics for quick recovery from sickness. The knowledge gap of Chinese physicians was evident and those with a higher degree of knowledge always prescribe fewer antibiotics. The National Health Commission of the People’s Republic of China[27] had made more special efforts to enhance health education on the rational drug use and antimicrobial resistance[28], develop more targeted policies[29] and programs for prescription practice at medical facilities.
The results of WHO/INRUD Indicator Studies in developed and developing countries[30] had showed in table 5, our results of table 2, table 3 and table 4 were different from the table 5, any indicator were out of range of WHO optimal value and Africa standard in table 1. Targeted training and courses to educate physicians about the risks of over-prescription should be conducted to improve the practice of antibiotic prescriptions. The governments should also take action to control antimicrobial resistance[6, 31] according to WHO ‘Global action plan on antimicrobial resistance’ [28].
Discussion of Economic view
‘Health in the 2030 Agenda for Sustainable Development’ [32] pointed out that Sustainable Development Goals included much broader range of environmental, economic and social issues. WHO reported supporting a total of 241 South–South and/or triangular cooperation initiatives[32], 47% covered health systems and universal health care, 30% covered promoting health through the life-course and 16% covered other issues. In addition, 74% included training and capacity-building, 76% of initiatives included technical support, 32% provided financial[33] and equipment support and 18% providde other services. Essential medicines [34, 35]covered a wide range of diseases which could decrease medical expenditure, including pain management and palliative care. Data from health facility surveys conducted nationally in 29 countries during the period 2007–2017[32, 33] indicate that 58% of public-sector facilities surveyed in lower-middle income countries stocked medicines for pain management and palliative care.
Chinese medical insurance was consisted of commercial health insurance and social medical insurance[36]. The latter was consisted of basic medical insurance system for urban and township employees and new rural cooperative medical system. Our outpatient Economic Indicators of 2012-2014 was shown in Table 4. According to the statistical bulletin of national economic and social development of Jingzhou[11, 12] in 2019, there are about 6,412,800 registered residents, 1,113,600 urban residents. There are about 3,204 medical institutions, 31,342 beds and 42,145 medical professionals. Though average drug cost per prescription increased from 191.31 to 363.22 RMB, the percentage of antibiotic cost in the daily drug cost remarkably decreased from 17.44% to 8.01%.
Chinese Zhuhai's [36]new expenditure per common disease outpatient and prescribing indicators were benefited from medical insurance and expanded access to primary care, but it could led to reduction in expensive specialist inpatient services. More explicit incentives and specific quality of medication prescribing targets need to be incorporated into the insurance system.