Nolte Ellen, Newbould Jennifer, Conklin Annalijn
Rand Health Q. 2011 Mar 1;1(1):4. eCollection 2011 Spring.
This article describes a review of the published and grey literature on international variation in the use of medicines in six areas (osteoporosis, atypical anti-psychotics, dementia, rheumatoid arthritis, cardiovascular disease/lipid-regulating drugs (statins), and hepatitis C). We identify three broad groups of determinants of international variation in medicines use: (1) Macro- or system level factors: Differences in reimbursement policies, and the role of health technology assessment, were highlighted as a likely driving force of international variation in almost all areas of medicines use reviewed. A related aspect is patient co-payment, which is likely to play an important role in the United States in particular. The extent to which cost-sharing policies impact on overall use of medicines in international comparison remains unclear. (2) Service organisation and delivery: Differences in access to specialists are a likely driver of international variation in areas such as atypical anti-psychotics, dementia, and rheumatic arthritis, with for example access to and availability of relevant specialists identified as acting as a crucial bottleneck for accessing treatment for dementia and rheumatoid arthritis. (3) Clinical practice: Studies highlighted the role of variation in the use and ascertainment methods for mental disorders; differences in the use of clinical or practice guidelines; differences in prescribing patterns; and reluctance among clinicians in some countries to take up newer medicines. Each of these factors is likely to play a role in explaining international variation in medicines use, but their relative importance will vary depending on the disease area in question and the system context.
本文介绍了对已发表文献和灰色文献的综述，这些文献涉及六个领域（骨质疏松症、非典型抗精神病药物、痴呆症、类风湿性关节炎、心血管疾病/调脂药物（他汀类药物）以及丙型肝炎）药物使用的国际差异。我们确定了药物使用国际差异的三大类决定因素：（1）宏观或系统层面因素：报销政策的差异以及卫生技术评估的作用，在几乎所有所审查的药物使用领域中，都被视为国际差异的一个可能驱动力。一个相关方面是患者自付费用，这在美国可能尤其重要。在国际比较中，成本分担政策对药物总体使用的影响程度尚不清楚。（2）服务组织与提供：获得专科医生服务的差异，可能是导致非典型抗精神病药物、痴呆症和风湿性关节炎等领域出现国际差异的一个因素，例如，获得相关专科医生服务的机会和可及性，被认为是痴呆症和类风湿性关节炎治疗的关键瓶颈。（3）临床实践：研究强调了精神障碍使用和确诊方法的差异；临床或实践指南使用的差异；处方模式的差异；以及一些国家的临床医生不愿采用新药的情况。这些因素中的每一个都可能在解释药物使用的国际差异方面发挥作用，但其相对重要性将因所讨论的疾病领域和系统背景而异。
