Soumerai S B, Ross-Degnan D, Gortmaker S, Avorn J
Department of Social Medicine, Harvard Medical School, Boston, MA 02115.
JAMA. 1990 Feb 9;263(6):831-9.
Little is known about the effect on clinical decision making of nonreimbursement for ineffective medical technologies. Using a time-series design, we studied the effects of cessation of government payment for 12 categories of drugs of questionable efficacy (Drug Efficacy Study Implementation drugs) in a random sample of the New Jersey Medicaid population (N=390 465) and in four cohorts of regular users of these products. We measured changes in the overall levels of prescriptions, expenditures, and physicians' use of substitute drugs. Although withdrawn drugs accounted for 7% of prescriptions in the base year, there was no measurable reduction in overall drug use or expenditures after the regulation; prescription rates actually rose from 0.86 to 1.00 monthly prescriptions per enrollee throughout the 42-month study. Controlling for preexisting trends, an estimated drop in the use of study drugs of 21.7 prescriptions per 1000 enrollees per month was offset by an increase in the use of substitute drugs of 33.7 prescriptions. Both desirable and unimproved therapeutic substitutions were observed. Used alone, curtailment of reimbursement for marginally effective therapies results in both desirable and unintended clinical substitutions and may not reduce costs. Supplementing such restrictions with education may be necessary to promote practices that are more therapeutically and economically appropriate.
关于无效医疗技术不予报销对临床决策的影响，目前所知甚少。我们采用时间序列设计，在新泽西医疗补助人群的随机样本（N = 390465）以及这些产品的四个常规用户队列中，研究了停止对12类疗效存疑药物（药物疗效研究实施药物）的政府支付所产生的影响。我们测量了处方总量、支出以及医生使用替代药物情况的变化。尽管在基准年中，撤市药物占处方量的7%，但该规定实施后，总体药物使用量或支出并未出现可测量的减少；在整个42个月的研究中，每位参保人的处方率实际上从每月0.86张升至1.00张。在控制了先前趋势的情况下，每1000名参保人每月研究药物使用量估计下降21.7张处方，被替代药物使用量增加33.7张处方所抵消。观察到了理想的和未改善的治疗替代情况。仅靠减少对疗效欠佳疗法的报销，会导致理想的和非预期的临床替代情况，且可能无法降低成本。可能需要通过教育来补充此类限制措施，以促进在治疗和经济方面更合理的做法。
